THE WELFARE 

OF THE 
SCHOOL CHILD 




JOSEPH GATES. M.D. 




Glass AIBMOS, 
Book - C 3 



PRESENTED BY" 



ENGLISH PUBLIC HEALTH SERIES 
EiUed by Sir Malcolm Moious, K,C.V.0. 



THE WELFARE OF THE 
SCHOOL CHILD 




•7 S 



The Welfare 
of the School Child 



BY 

JOSEPH GATES 

M.D. State Medicine, B.S.Lond., D.P.H.Gamb. 

Medical Officer of Health and School Medical Officer, St. Helens ; formeriy 
Demonstrator of Public Health at King's College, University of Loodi>n 



With Six Half-tone Plates 



NEW YORK 
FUNK AND WAGNALLS COMPANY 



V^r'.^ 






mat 

Pnblishei' 
SEP a iS2Q 



PREFACE 

In these pages an attempt has been made to show 
the importance of healthy environment for the wel- 
fare of the school child. Attention is directed in 
various sections of the book to the need for com- 
prehensive and complete Public Health adminis- 
tration. The School Medical Service in the early 
stages of its growth was largely occupied in the 
detection and treatment of defects. The time has 
now come to attack the beginnings of disease and 
the causes of illness. Under the direction of the 
Ministry of Health all the forces of Preventive 
Medicine must be marshalled for the fray. 

In preparing the book, use has been made of 
the publications of Government Departments, and 
in particular the Annual Reports of the Registrar- 
General and of the Medical Officers of the Local 
Government Board and the Board of Education. 

To my friend Dr. Austin Nankivell I am deeply 
indebted for valuable criticisms and advice. 

J.C. 



CONTENTS 



Introduction 

The National Importance of Healthy Childhood — Ante-natal 
Conditions — Effects of Parental Sickness — Venereal 
Disease — Maternal Inexperience — Industrial Employment 
of Mothers — Parental Occupation and Infant Mortality — 
Domestic Overcrowding — Defective Sanitation — Artificial 
Feeding — ^Need for the Reorganisation of Health 
Administration i 

CHAPTER I 
Malnutrition 

Nutrition — Causes of Malnutrition : Insufficient or Unsuit- 
ahle Food — Insanitary Conditions in and around the 
Home — ^Want of Sleep — ^Disease — Unsuitable Em^ploy- 
tnent. Prevention of Malnutrition ; Educating the 
Mother — The Healthy Home — Institutional Treatment — 
A Home Nursing Service — 'Combating Malnutrition in 
the School 16 

CHAPTER II 
Dental Diseases 

Dental Decay — Pyorrhoea — Overcrowding of the Teeth — 
Causes of Dental Disease — Preventive Measures : En- 
lightenment of Patents — ^Toothbrush Drill in School — 
Dental Inspection and Treatment — ^Dental Clinics — 
Need for a more Comprehensive Scheme • • • 35 



viii Contents 

PAGB 

CHAPTER III 
Defects of Vision, Hearing, and Speech 

Defects of Sight: Prevalence among Children—Causes — 
Treatment of Minor Eye Ailments — Treatment of Errors 
of Refraction — Special Classes — Institutions for the 
Blind. Diseases of the Ear and Defects of Hearing : 
The Chief Causes — Pievention — Education of the Deaf. 
Stammering : Probaible Cause — Prevention and Treat- 
ment — Special Classes — Following up the Cases — 
Revision Classes 4* 

CHAPTER IV 
Heart and Lung Disease 

Diseases of the Heart : Inflammation of the Cardiac Mem- 
branes and Valves — ^Causes — ^Congenital Cases — Func- 
tional Disorders — Prevention — Institutional Treatment. 
Diseases of the Lung : Bronchitis — Pulmonary Tubercu- 
losis — Chronic Broncho-pneumoiia — Prevention of Lung 
Diseases — Domestic Treatment — Institutional Treat- 
ment 56 

CHAPTER V 
Minor Ailments 

Ringworm — Scabies — Infestation with Vermin — Injuries — 
Sclhool Attendance and Illness— The Exclusion of 
" Contacts " — ^An Alternative System . . . . 66 

CHAPTER VI 
The Cripple-Child 

Unsuitability for Cripple-children of Ordinary Schools — 
Approximate Number of such Children — Inadequacy 
of the Provision for them — 'Causes of Deformity — 
Surgical Tuberculosis — Infantile Paralysis — Rickets — 
Faulty Posture — ^How to treat Crippling iDiseases . 79 



Contents ix 

PAGE 

CHAPTER VII 
The Mentally Abnormal Child 

the Backward Child— The Dull Child— The Feeble-minded 
Child — Day Schools, Residential Schools, and Per- 
manent Homes for Feeble-minded Children — Epileptics 
— After-care 91 

CHAPTER VIII 
School Buildings 

Influence of School Buildings — Defective Schools — Situation 
and Site — Self-contained Departments — The Class- 
room — ^Ventilation and Heating— Water Supply — The 
Cloak-room — Sanitary Accommodation — ^^Class-room Ap- 
pliances — Lighting — Accommodation for the Staff . . 104 

CHAPTER IX 
The School Annexe 

The Canteen — Advantages of School Meals — The Gymnasium 
and its Equipment — Indoor Games — Dancing — Pocket- 
handkerchief Drill — Facilities for Swimming — School 
Bath.s — Play Centres — Treatment Centres — The Nursing 
Staff 118 

CHAPTER X 

Special Schools 

Open-air Schools — Open-air Residential Schools — School 
Camps — Sanatorium Schools for Pulmonary Tuberculosis 
— Cripple Schools — Special Schools for the Blind and 
Deaf 134 



INDEX ... 149 



LIST OF HALF-TONE PLATES 

PLATE FACING PAGE 

1. The mid-day rest ....... 

Frontisfiece. 

2. A class-room canteen ...... r8 

3. Dentist's room of a school clinic . . . . 40 

4. X-ray room of a school clinic . . . .68 

5. An infants' class-room 112 

6. Operating-room of a school clinic .... 130 



THE WELFARE OF 
THE SCHOOL CHILD 

INTRODUCTION 

The nation has emerged victorious from the 
terrible ordeal of a European war. A four- 
years' deathly combat has left upon her 
marks which time alone can efface. Freely 
she threw into the fight her best of men and 
her gold, yet there were moments in that 
long night when it almost seemed that her 
efforts would be without avail. The day of 
triumph dawned, and with it came a pesti- 
lence more destructive than the ravages of 
war, taxing mainly, too, the lives of healthy 
adults. So serious was the epidemic that 
in many districts the death-rate was more 
than double the rate at which children were 
born. In some homes nearly every member 
of the family died. 



The School Child 

Happily, there is no doubt that from 
both war and disease the country can re- 
cover, and can make up the loss in man-power 
and in wealth. 

An earnest, whole-hearted attempt must 
be made to build up a healthy nation. 

Systematic medical inspection has re- 
vealed an appalling amount of disease and 
defect among the children attending the 
public elementary schools, and examinations 
carried out for recruiting purposes during 
the War have brought to light the crippling 
effects of illness in childhood. 

The experience of the School Medical 
Service goes to show that 80 per cent, of 
school children need dental treatment, 10 
per cent, are suffering from malnutrition, 
20 per cent, from eye defects, 3 per cent, 
from disease or defect of the ears, and the 
same proportion from enlarged tonsils and 
adenoids. There are as well a large number 
with so-called minor ailments, conditions 
which, untreated, are often the beginning 
of serious disabling disease. 

From an economic standpoint it is an 
unsound policy to provide a system of edu- 



Introduction 

cation and leave untouched defects which 
prevent a child obtaining full benefit there- 
from. The financial burdens willingly under- 
taken by the State call for the strenuous 
exertions of every member of the community 
to increase the output from factories and 
workshops and from the land. Highly skilled 
workers are needed not only for industrial 
processes long established but for the per- 
fecting of trades in markets yet to be won. 
The physically sub-normal children unequal 
to compete with the able-bodied, and as a 
rule insufficiently educated to obtain any 
kind of clerical work, furnish the majority 
of the recruits for the ranks of the unem- 
ployed. At a later stage many of them 
become destitute, and a lifelong charge on 
the nation. In the narrowest aspect it is 
surely advisable to secure adequate treat- 
ment, and in certain instances, by special 
methods of training, make those ailing and 
defective children an asset of the State. 

But a broader view must be taken of the 
national importance of healthy childhood. 
The weakly boy, the feeble youth, the physic- 
ally inefficient man, are but stages in the 

3 



The School Child 

journey along which diseases of infancy pass 
unchecked. 

A C3 population does not acquire its 
characteristics in a day, nor does it pass 
away without leaving a legacy. 

In considering the welfare of the child 
of school age some thought should be given 
to influences which have already begun to 
mould the plastic frame. The effects of un- 
favourable ante-natal conditions, and the 
dangers that beset the infant and the young 
child, form the themes of other volumes in 
this Series* ; but the present volume will 
lack completeness unless those conditions and 
dangers are glanced at in these introductory 
pages. 

Each infant, then, carries into school the 
result of five years of home life. For good 
or for evil this period will be largely respon- 
sible for the physical and mental condition 
of the entrant to school. 

Parental ignorance, the illnesses of baby- 
hood, an unhealthy home — these and other 
factors go to make the ailing, puny child, 

* See "The Welfare of the Expectant Mother," by Mary 
Scharlieb, C.B.E., M.D., M.S., and " Infant and Young Child 
Welfare," by Harold Scurfield, M.D., iD.P.H.Camb. 1919. 

4 



Introduction 

and no scheme to safeguard the health of 
the school child is likely to show complete 
success unless there is included the care of 
the infant under school age. 

But the health of the ba5y does not begin 
at birth. At least nine months before is a 
vulnerable period, during which, when life 
is not destroyed, the career of the future 
infant may be materially crippled. 

Of the extent to which ante-natal con- 
ditions cause infant mortality, sickness, and 
a low standard of health in childhood, youth 
and adult life, it is as yet impossible to speak 
with any degree of certainty. The laws 
dealing with the registration of births and 
deaths expressly exclude any official record 
of stillbirths. Neither is it known with what 
frequency miscarriages occur. It has been 
estimated that two stillbirths and nine mis- 
carriages take place for every hundred live 
births. In other words, there is a mortality 
of infants before birth as great as that 
which occurs among the survivors during 
the first year of life. A special inquiry in 
one large city showed that no less than 
25 per cent, of pregnancies failed to result 

5 



The School Child 

in a living full-time child. During the 
year 1917 over 20,000 deaths of children 
under one year of age were certified as due 
to premature birth. 

Ante-natal causes, therefore, exact a 
heavy toll during the nine months of foetal 
life, and it is only reasonable to expect that 
they continue to operate after birth. 

In 1917, out of 64,483 deaths occurring 
in children under one year of age, 25,044 
took place within a month of birth, and 
8,355 of these occurred within a week. No 
less than 7,377 babies failed to survive the 
first day of life, and it appears fair to assume 
that for the cause of the majority of these 
deaths search must be made among influ- 
ences acting through the parents. 

Reference to the different causes of death 
in infancy affords striking evidence of the 
importance of parental health. 

Premature birth, congenital defects, and 
wasting diseases together were responsible, 
at least so far as certificates of deaths can 
be accepted as trustworthy evidence,, for 
76 out of every loi deaths during 1917 in 
children under one year of age. 

6 



Introduction 

It is safe to conclude that the majority 
of deaths due to these conditions are attribut- 
able to causes acting before birth, and also 
to lack of care and skilled assistance at the 
time of confinement. 

When it is realised that out of a thousand 
pregnancies, ante-natal causes bring about 
within a year and nine months a fatal ter- 
mination in approximately two hundred in- 
stances, some idea will be obtained of the 
magnitude of the devastation. It may be 
useful, therefore, to attempt to define some 
of the unfavourable influences which may 
act through the parents before the birth of 
their offspring, and to discover in what 
measure they may be prevented. 

Of the amount of infant sickness and ill- 
health during childhood and youth attribut- 
able to ante-natal causes, there is as yet 
insufficient evidence to warrant a definite 
estimate. However, it may be said that a 
high infant death-rate in a given community 
implies in general a high death-rate in the 
next four years of life, while a similar asso- 
ciation is found between low death-rates at 
both age-periods. 

7 



The School Child 

It has been shown that children of school 
age suffering from malnutrition commonly 
come from families where there has been a 
relatively high rate of infant deaths, and it 
may be expected that any condition likely 
to bring about infant death will certainly 
entail a large amount of sickness in child- 
hood. 

The effect of parental sickness on the 
health of the children is more important 
than might at first sight appear. Ill-health 
of the father, tending to inefficiency as a 
workman, leads to poverty and domestic 
privation, and causes the family to drift 
into insanitary surroundings. Maternal sick- 
ness often brings about neglect of infant care, 
the abandonment of breast-feeding, and lack 
of attention to general household duties. 
Venereal disease is a potent agent in infant 
mortality. Evidence given before the Royal 
Commission on Venereal Diseases showed that 
of 102 children examined at a blind school, 
in 47 instances the blindness was due to 
venereal disease. A similar investigation at 
a French institution suggested that 50 per 
cent, of cases of blindness could be traced 

8 



Introduction 

to the same cause. Another witness stated 
that the histories of 34 syphiHtic mothers 
showed that only 16 per cent, of children 
born alive were apparently or doubtfully 
healthy, 

A high infant mortality may arise from 
the inexperience associated with unduly early 
motherhood. The home surroundings of the 
child of parents marrying before they are 
able to maintain a suitable home are likely 
to affect prejudicially the infant's physical 
condition. It has been shown that counties 
with a high proportion of wives under age 
have a high infant death-rate, and, on the 
other hand, that those with a low propor- 
tion of wives under age have a low rate of 
infant mortality. In this respect it must 
be remembered that the counties in which 
marriage is postponed to a more mature 
age are chiefly rural in character. 

Certain occupations of parents, and par- 
ticularly the industrial employment of 
mothers, have an unfavourable ante-natal 
effect on the health of their children. Bcr 
yond this, there is the even larger question 
of the neglect of home life and the lack of 

9 



The School Child 

motherly care and attention experienced by 
the children left under the charge of an 
elder child or a neighbour. Artificial feeding 
is resorted to at the earliest possible moment, 
with the attendant evils of unwholesome, 
contaminated food improperly prepared. At 
the close of a day of heavy work the em- 
ployed mother has little inclination or physi- 
cal capacity to carry out those important 
domestic duties essential to the cleanliness 
of the house and the comfort of the family. 
The occupations of parents are so in- 
timately bound up with social position and 
home sanitation that it is difficult to eliminate 
the other considerations involved. It is 
notorious, however, that deaths from measles, 
whooping-cough, and similar diseases are 
relatively rare among the children whose 
parents belong to the upper and middle 
classes. Statistics recently compiled show 
that the death-rate of children 6 to 12 
months of age whose fathers were clergymen 
was 16. 1 per 1,000 births, while the infants 
of sandwichmen and bill distributors died 
at the rate of 166. Nor is the reason far to 
seek. The former have the advantage of 

10 



Introduction 

well-ventilated rooms and clean, wholesome 
food, and generally spend their childhood 
under efficient supervision and sanitary sur- 
roundings. The latter, fed on unclean and 
unsuitable food, housed under conditions of 
poverty and overcrowding, are left to play 
about in yards and passages, exposed to all 
the dangers of defective sanitation. 

A relation has been stated to exist be- 
tween moderately small families and a low 
infantile mortality, and it is probable that 
any connection between a high birth-rate 
and a high rate of infant death arises from 
the fact that large families are common 
among the working classes, and that these 
classes are particularly exposed to influ- 
ences unfavourably affecting infant and child 
life. Large families frequently tend towards 
some degree of poverty, forbidding removal 
into a house sufficiently roomy for proper 
accommodation. Domestic overcrowding 
therefore follows, with its innumerable evils. 

Domestic overcrowding is responsible for 
a large proportion of the minor ailments 
affecting childhood. Children are anaemic, 
ill-nourished, and puny because they have 

II 



The School Child 

insufficient room in which to live, impure 
air to breathe, and unclean, unsuitable, and 
improper food to eat. 

Undoubtedly, the outstanding cause of 
death and disease among children is defective 
sanitation, either in the house or in its imme- 
diate surroundings. The injurious effect of 
insufficient accommodation for washing and 
of the absence of proper storage for food is 
not likely to be denied. Unpaved yards, 
middens, pail closets and uncovered ashpits 
are effective weapons with which to destroy 
young life. The results of insanitation can 
be seen in an excessive death-rate from 
diarrhoeal diseases and in the prevalence of 
other preventable illnesses of childhood. A 
high death-rate implies a high rate of 
damage among survivors. For every infant 
that succumbs there are many who just 
manage to survive, and are left as battered 
wrecks on the ocean of life. The permanent 
crippling effect of disease is as yet imper- 
fectly appreciated. 

It is fair to assume that parental ignor- 
ance and poverty are closely related to the 
prevalence of sickness and death in child- 

12 



Introduction 

hood. Want of knowledge on the part of 
parents is mainly responsible for two sources 
of risk to child life, namely, artificial feeding 
and food contamination. 

It is true that artificial feeding is common 
among the children of the upper and middle 
classes — sections of the community with a 
relatively low rate of death. On the other 
hand, an increasing prevalence of breast- 
feeding among working-class mothers is coin- 
cident with a diminution in infant mortality. 
The child of a professional man, born into 
a favourable environment, possessing every 
advantage afforded by nursing and medical 
skill, can be placed on a carefully selected 
artificial food, prepared under hygienic con- 
ditions, without risk to health or physical 
development. The infant of an unskilled 
labourer, compelled to live in insanitary sur- 
roundings, hafndicapped by the disadvantages 
of impure air and soil, finds the mother's 
milk a safeguard against the dangers of 
polluted and suitable food. To such a child, 
artificial food, unless municipal enterprise 
intervenes, may be cow's milk of an in- 
ferior quality, grossly contaminated before 

13 



The School Child 

delivery in the home ; or some indigestible 
substance improperly prepared in a dirty 
utensil, and exposed to dust and flies. 

Lack of facilities for the immediate treat- 
ment of small childish ailments, too often 
neglected owing to their apparent triviality, 
and the absence of skilled nursing during 
serious illness, are answerable for much 
easily preventable suffering and physical dam- 
age during the early years of life. The 
serious after-effects of diseases such as measles 
and whooping-cough, and the deformities 
arising from acute poliomyelitis (infant 
paralysis) and tuberculosis, could be largely 
prevented were adequate nursing assistance 
available for the community. 

The health of the school child, it must 
be repeated, depends very largely on the 
health of the parents and the environment 
during babyhood. Much of the disease and 
defect caUing for treatment during school 
age has a beginning in the first years 
of life, and could be prevented by appro- 
priate Public Health measures. Further 
facilities for the education of the prospec- 
tive mother, the establishment of maternity 

14 



Introduction 

centres, the provision of an adequate num- 
ber of trained nurses as health visitors on the 
staff of each Medical Officer of Health, and 
sufficient hospital accommodation, are 
urgently needed in almost every locality. 
Under the Ministry of Health it is to be 
hoped that both central and local adminis- 
tration will be reorganised, so that the pre- 
vention and treatment of disease may be 
carried out by one Service under one control 
and that vested interests will no longer be 
permitted to obstruct the removal of con- 
ditions injurious to life. 



15 



CHAPTER I 
Malnutrition 

In the first five chapters of this book we shall 
consider the case of the physically defective child 
— the child who is the victim of malnutrition, or 
who has defects of teeth, of vision, of hearing, or 
of speech, or who suffers from heart or lung 
disease or from minor ailments. Of these physical 
defects, brought to light by systematic medical 
inspection in schools, malnutrition is probably the 
most important, both to the nation and to the 
individual child. Its widespread prevalence, the 
obscurity of its origin, and the insidiousness of 
its onset combine to make it a problem that cannot 
be ignored. 

Nutrition is a comprehensive term embracing 
a complex condition. It may be regarded as one 
of the most reliable signs of a healthy body, the 
various systems of which are properly carrying 
out their physiological functions. In estimating 
the state of nutrition, there is to be taken into 
account the relationship between the height and 
weight of the child, its general demeanour, the 

i6 



Malnutrition 

texture of the muscles, and the appearance of the 
skin. Alert carriage, firm muscles with a cover- 
ing of fat, and a healthy elastic skin are evidence 
of good nourishment. 

As there are yet no definite and reliable stan- 
dards by which these various factors can be 
measured and no index that is generally applicable, 
the classification of the state of nutrition of a child 
will largely depend on the personal experience of 
the observer. It is not surprising, therefore, to 
find wide variations in the results of the examina- 
tions carried out by different School Medical 
Officers. In some areas a considerable departure 
from the average may be expected, owing to con- 
ditions peculiar to the locality, such as the pre- 
valence of child labour or Bad housing. 

But when allowance is made for the difficulties 
encountered in arriving at a decision in any par- 
ticular case, and for the influence of local con- 
ditions, there remains the fact that about a tenth 
of the child population attending the public 
elementary schools of the country is suffering from 
malnutrition, and that less than a half is well 
nourished. 

In considering the national and industrial 
aspects of the serious position revealed by the 
systematic medical inspections carried out since 
1908, it may be suggested that a successful stock- 
breeder would view with dismay the discovery that 
c 17 



The School Child 

less than half his young cattle were thriving and 
in good condition — in other words, well nourished. 
He would at once seek the cause, and, having 
found it, would bring about its removal and pre- 
vent a recurrence. 

Possibly he might find that the malnutrition 
was due to in-breeding, or to inherited disease 
or defect. It is more likely, however, that the 
feeding would prove to be at fault, the sheds 
insanitary or overcrowded, and the animals 
neglected. The stock might be recovering from 
the effects of some disease, or want of cleanliness 
might account for the failure to thrive. 

A healthy herd cannot be reared from ill- 
nourished young, nor can a vigorous race be 
expected from a school population in which a 
million children are suffering from malnutrition. 

In so far as this condition leads to physical 
unfitness and in many cases to definite disease, it 
imposes a tax on the community and reduces the 
earning power of the nation. 

The ill-nourished child is prone to minor ail- 
ments, susceptible to tuberculosis, listless, 
apathetic, Incapable of sustained mental effort. 

The causes of malnutrition are as yet imper- 
fecdy understood. It is certain, however, that 
among the more important are the following : — 

I. Insufficient or unsuitable food. — The 
rapidity with which ill-nourished children improve 

i8 



Malnutrition 

when in attendance at school canteens or after 
admission into institutions supports the assump- 
tion that either improper feeding or lack of food is 
a potent factor in the causation of malnutrition. 
While it is true that poverty may sometimes be 
ihe reason, it is much more usual to find that want 
of knowledge on the part of mothers of the value 
of the various foods, and inability to obtain by 
simple cooking the full nutriment from foodstuff, 
are chiefly responsible. 

The reports of School Medical Officers clearly 
show an appalling amount of ignorance in simple 
home cooking and in the general management of 
the house, but it must not be thought that mothers 
refuse to learn when an opportunity is offered. 
The success achieved by schools for mothers points 
the way along which future effort must be made. 

2. Insanitary conditions in the home* 
(a) Lack of air and sunlight. — The good results 
apparent in the health of children in attendance 
at open-air schools seem to furnish evidence that 
lack of air leads to ill-nourishment. 

Unless sunlight can enter every living-room at 
some period of the day, dirt and dust are likely to 
be allowed to accumulate. The destructive effect 
of the rays of the sun on germ life is an additional 
reason for the ample natural lighting of rooms. 

Staircases, passages and cupboards which are 
dark and ill-ventilated are difficult to keep clean 

19 



The School Child 

and dry. Dark recesses are often used as recep- 
tacles for various forms of refuse. Although con- 
siderable controversy has centred round the ques- 
tion of the effect of back-to-back houses on the 
health of the inhabitants, there can be no doubt 
that it is a method of construction which should 
unreservedly be condemned. In some districts 
householders are still permitted to erect without 
restriction buildings in back yards. The effect of 
this is further to reduce the already insufficient 
yard area, and to shut off a considerable amount 
of light and air. Even at the present day insuffi- 
cient use is made of the windows and other means 
of ventilation provided. 

Unfortunately, in many industrial areas the open 
window brings dirt and dust and a soot-laden air. 

(b) Overcrowding. — On every side there is an 
appalling dearth of houses. The supply of new 
houses before the War was not nearly equal to the 
demand. Since 1914 building has been almost 
suspended and repair of property has been 
neglected, with the consequence that overcrowding 
is rampant in most industrial areas and in many 
rural districts. One estimate has put the need at 
a million new houses. Accepting this, it follows 
that some four to five million persons are living 
under conditions of overcrowding. Obviously the 
health of the child is likely to be injured by the 
unfavourable mental, moral and physical surround- 

20 



Malnutrition 

ings associated with the overcrowding of persons 
in a room, particularly when that room is used for 
sleeping purposes. The vitiation of the atmo- 
sphere, the difficulty experienced in washing and 
cleaning, and the liability to contamination of food 
through lack of a suitable place of storage 
diminish vitality and retard nutrition. 

(c) Closet and refuse accommodation.— The 
offensive, insanitary privy midden and that equally 
disgusting modification of it, the pail closet, have 
a baneful effect on nutrition. These relics of the 
Middle Ages are detrimental to decency, they 
cause noxious effluvia, they encourage the presence 
of swarms of flies, and they lead to the fouling of 
yards and passages. Although it is not easy to 
demonstrate the exact part played by the substitu- 
tion of water carriage for the conservancy system 
in reducing infant mortality, since other important 
sanitary improvements are usually associated with 
it, such as the paving of back yards and the pro- 
vision of suitable dustbins, yet its value to health 
is beyond question. In one district the infant 
death-rate in houses with the water carriage was 
117; in those with pail closets or privy middens, 
250. It has been estimated that, other things being 
equal, by converting privy middens to water- 
closets a reduction in the infant death-rate of more 
than one-half may be expected. A high rate of 
infant mortality, as we have seen, is always asso- 

21 



The School Child 

ciated with a large amount of sickness and ill- 
health among the survivors. 

(d) The storage of house refuse. — Intimately 
related with the disposal of faecal matter is the 
storage of domestic refuse. Large, uncovered ash- 
pits, emptied at infrequent intervals, or wooden 
receptacles deposited in brick ashplaces, are dan- 
gerous and totally unsuitable. The accumulation, 
consisting of ashes and a mass of highly objec- 
tionable filth readily liable to decompose, forms a 
serious menace to health and decent living. 

(e) The yard and the street. — Much of the ill- 
health and consequent malnutrition of children 
during the summer and early autumn arises from 
the consumption of contaminated food. Outside 
school hours the yard and the street are the only 
playgrounds available to many of the children 
attending the public elementary schools. An un- 
paved or defectively paved surface with broken 
gullies and leaking channels allows waste and 
slop water to soak into the soil. In wet weather 
pools of water collecting in the yard are converted 
into puddles, into which garbage and other debris 
are thrown. Children playing in surroundings 
such as these soon become fouled with the dirt, 
which is carried into the house. In warm weather 
flies are attracted to the pools and the rotting 
material ; direct contamination of food in adjacent 
premises soon follows. 

22 



Malnutrition 

In yards common to several houses similar con- 
ditions will be found. A further disadvantage is 
that a yard which is shared by several houses is 
rarely kept clean. The influence of an undesirable 
tenant in one of the houses extends to the other 
members of the small community. The occupants 
of the other houses not unnaturally become dis- 
heartened on seeing their own efforts at cleanliness 
frustrated by a slovenly neighbour. 

Infectious and contagious diseases are more 
easily spread where there are ample opportunities 
for frequent contact in an open yard. With a 
common yard, too, is frequently found a common 
water supply. In districts where the sub-letting 
of houses is prevalent and the only water supply 
a tap on the ground floor, the use of clean water 
will be reduced to a minimum. 

Much of what has already been said with re- 
gard to unpaved yards applies with equal force 
to unpaved passages. Unless efficient sweeping is 
carried out daily these passages are little less than 
a refuse tip for the adjoining houses. 

No less important is the state of the paving and 
cleansing of streets. It would often seem that the 
health aspect of this question had been entirely 
overlooked. Dirty streets are the precursors of 
disease, and children are the first to fall victims to 
it. Horse-manure and other refuse trodden under- 
foot in wet weather is splashed over pedestrians 

23 



The School Child 

and over food displayed in shop windows. During 
dry seasons a cloud of dust, mainly composed of 
finely powdered manure and human expectoration, 
is blown over fruit and other foodstuffs and into 
the houses. In towns where considerable at- 
tention has been paid to the paving and tar 
dressing of roads, it has been noted that dirt-borne 
diseases, such as impetigo in children, are rarely 
seen.* 

3. Want of sleep. — The investigations carried 
out by school nurses show that malnutrition can 
often be traced to insufficient sleep. Few children 
obtain the rest that a growing animal requires. 

Where sleeping accommodation is restricted 
and children share a bed with their parents the 
health of the child is certain to suffer. 

In institutions it is found that children will 
sleep for twelve hours, even though they may not 
appear tired when going to bed. 

4. Disease. — Malnutrition can at times be 
traced to definite disease or defect. Some ill- 
nourished children are suffering from tuberculosis, 
while others are in a condition particularly sus- 
ceptible to infection — the pre-tubercular state. 
Measles and whooping-cough, among the acute 
diseases of childhood, often sow the seeds of long 

* For a fuller consideration of insanitary conditions in and 
around the home, see " Housing and the Public Health," by John 
Robertson, C.M.G., O.B.E., B.Sc, M.D. 1919. (English Public 
Health Series.) 



Malnutrition 

periods of ill-health. From diphtheria recovery is 
slow, and the tone of the muscles is generally late 
in reappearing. 

The importance of measles alone as a cause of 
malnutrition must be considerable, since nearly 
half the children entering school have suffered from 
the disease, and of the remainder about 50 per 
cent, contract it during school life. 

Enlarged tonsils and adenoids are usually asso- 
ciated with subnormal nutrition ; so also are many 
of the minor ailments — sore eyes, recurring im- 
petigo, and discharging ears. Reference has 
already been made to the widespread effects of the 
consumption of contaminated food and the con- 
sequent malnutrition. 

To understand the magnitude of the danger 
to health arising from food-poisoning, it must be 
realised that in insanitary areas almost every 
home experiences an annual outbreak of summer 
diarrhoea. 

Few diseases so sap vitality and so rapidly 
undermine nutrition as this form of diarrhoea. 
Within the space of hours a healthy, robust child 
may be brought to the verge of death, and for 
several weeks may remain pallid, listless and 
flabby, with hardly a trace of the previous well- 
nourished condition. 

Apart from sudden attacks of enteritis, food- 
poisoning is undoubtedly at the root of much of 

25 



The School Child 

the sickness and malaise so common among chil- 
dren, and particularly among those attending the 
infant departments. 

Rheumatism, either in its acute form as rheu- 
matic fever, or in its sub-acute manifestations, is 
certainly a factor to be considered when inquiring 
into the possible causes of malnutrition. Recur- 
ring attacks of sore throat, "growing pains," bouts 
of raised temperature associated with headache, 
fleeting pains in the joints, transient rashes at 
times accompanied by painful rheumatic nodules, 
may be signs of the infection. St. Vitus's dance, 
or chorea, is probably in origin closely related to 
rheumatism. 

The ill-effects of decayed teeth and oral sepsis 
are now becoming more widely known. Than 
dental caries, probably, no disease is more easily 
preventable, more amenable to treatment, or, when 
left untreated, more liable to increase. It leads to 
ill-health and malnutrition in several ways. Thus 
it may cause a spreading infection of the gums and 
teeth sockets, extending to the jaw. Enlargement 
of the lymphatic glands lying below the jaw, and 
at times abscess formation follow. The toxins pro- 
duced by the disease germs are absorbed into the 
blood, and a poisoning of the body ensues. Puru- 
lent matter oozing into the mouth is continually 
being swallowed, with the result that the child 
shows signs of gastro-intestinal disturbance. 

26 



Malnutrition 

Anaemia, indigestion, joint-pains, headache, and 
a disinclination for exertion are further evidence of 
damage to the system, due to an apparently trivial 
defect in the mouth. 

Bronchitis is relatively common in children, 
especially among those entering school, and, as a 
rule, those suffering from bronchitis are ill- 
nourished. The disease is probably due to a mild 
infection of the respiratory passages, the down- 
ward extension of a septic condition of the mouth, 
nose, or throat. Unhealthy homes, and particu- 
larly dark, ill-ventilated bedrooms aggravate the 
complaint, and parental ignorance often allows a 
vicious circle to be established. Owing to recur- 
ring attacks of bronchitis the child is kept heavily 
clothed, expansion of the chest and free movement 
of the limbs are restricted. The skin, always moist, 
becomes susceptible to changes of temperature. 
Fresh air is avoided lest the child should take 
further cold. 

5. Unsuitable employment. — In a well- 
nourished child there is an accurate balance 
between absorption and excretion, between the 
energy obtained from food and the work performed 
by the body. Broadly speaking, the greater the 
amount of exercise the more food must be provided 
for the muscles. 

Overwork, combined with insufficient sleep, 
rapidly leads to malnutrition, and is one of the 

27 



The School Child 

main causes of ill-nourishment in children ap- 
proaching the age for leaving school. 

School Medical Officers are unanimous in the 
opinion that the employment of children is detri- 
mental to health. The children are tired when 
they reach school. Bodily and mental slackness 
characterises their work. 

How to prevent malnutrition. — Prevention 
of ill-nourishment lies in two directions — the home 
and the school. The reports of School Medical 
Officers indicate that about 12 per cent, of children 
entering school are below normal nutrition. Clearly, 
therefore, prevention to be successful must begin 
before school age. 

Education of the mother. — The teaching may 
be immediate or remote. The former consists of 
advice and instruction given at schools for mothers 
and maternity centres. The teaching must be 
simple, practical and interesting. It must embrace 
the preparation of nutritious, appetising dishes 
from ordinary articles of food, the dangers and 
prevention of the common infectious diseases, the 
cutting-out and making of children's garments, 
and general home management. Much good is 
likely to accrue from the home visits of capable 
trained nurses on the staff of the Medical Officer. 

It is possible by home visiting to gain the con- 
fidence of mothers to a degree rarely otherwise 
attained and to make the visit the occasion of 

28 



Malnutrition 

tactful inquiry into the home circumstances, the 
health of all the members of the family, and the 
general sanitary condition of the house. 

Remote teaching is that given to the elder girls 
in the public elementary schools, and to those who 
have left school but are in attendance at continua- 
tion schools or the evening classes of the technical 
schools. The value of the instruction may be some- 
what diminished by the interval that naturally will 
elapse before the girls become mothers, a difficulty 
likely to be surmounted by the raising of the age 
for leaving school and by the institution of con- 
tinuation schools; yet there is abundant proof 
that the teaching of mothercraft to senior girls is 
extremely important — and sadly neglected. 

It is essential that the instruction should be by 
a fully-trained, experienced nurse, and that the 
girls should have ample opportunities for practical 
work — the washing and dressing of a baby, the 
preparation of the cot, and infant feeding. 

There is much to be said for the suggestion 
that the girls should attend a maternity centre or 
school for mothers. There the facilities for prac- 
tical demonstration exist, and the nurses in attend- 
ance are available as teachers. 

The healthy home. — The health of the nation 
demands that every individual should have a home 
which is sanitary and is structurally adapted for 
a reasonable standard of cleanliness and comfort. 

29 



The School Child 

In most industrial areas and in many rural districts 
the housing conditions, as we have seen, are a 
cause of illness and death in the child population. 
Until the insanitary areas are swept away and the 
dispossessed inhabitants decently re-housed, mal- 
nutrition will be prevalent in public elementary 
schools. 

Every house should have as a minimum — 

A water supply within the house, a sink, 

a wash boiler and a bath. 
The means for adequate ventilation and light 

in every room. 
Fly-proof storage for food. 
A fly-proof receptacle for house refuse. 
A water-closet. 
A back yard completely paved. 

The occupants must be taught how to make 
the best use of the means of cleanliness and ventila- 
tion provided, the dangers of dirt, the steps to be 
taken when illness occurs, and the agencies from 
which medical and nursing assistance may be ob- 
tained in time of need. 

The local sanitary authority — the Town Coun- 
cil, the Urban or Rural District Council — must see 
that the surroundings of the houses are kept in 
wholesome condition. House refuse should be 
removed at least twice a week for destruction by 
fire. Streets and passages should be thoroughly 

30 



Malnutrition 

cleansed every night, and a liberal amount of water 
should be used for the purpose. 

The beneficial effect of a thorough cleansing 
with water can be seen during a wet summer in 
the reduction of the death-rate from diarrhoea. 

Institutional treatment and a home-nursing 
service. — ^The prevention of malnutrition due to 
definite disease obviously lies in an attempt to 
check the occurrence of the disease and in adequate 
and early medical attendance for the sufferers. 
Much depends on efficient Public Health adminis- 
tration — a pure soft-water supply, clean milk from 
herds free from tuberculosis, prompt measures on 
the outbreak of infectious disease, and regular 
sanitary inspection of the area. In two directions, 
however, local authorities have it in their power to 
strike directly at the root gf malnutrition due to 
disease. They can provide institutional treatment, 
and they can establish and maintain a home- 
nursing service. 

There is in most districts hospital accommoda- 
tion for scarlet fever, diphtheria and typhoid fever. 
In the larger centres of population there are general 
hospitals to which acute non-infectious diseases 
and accidents are admitted. But, broadly speak- 
ing, there is practically nowhere adequate hospital 
accommodation for those serious ailments of child- 
hood which are directly responsible for much of 
the malnutrition found in elementary schools. 
, 31 



The School Child 

Measles, whooping-cough, pneumonia, bronchitis, 
summer diarrhoea, tuberculosis, acute rheumatism 
and chorea, potent factors in the production of 
malnutrition, cannot as a rule be treated satisfac- 
torily in the homes of the working classes. It is 
rare that a bedroom can be set apart for the patient, 
and frequently it is impossible to provide a sepa- 
rate bed. The mother, tired out by her household 
duties, can scarcely keep awake during the night. 
She has little or no knowledge of those details of 
home nursing on which the safety of the sufferer 
may depend. The occurrence of fatal complica- 
tions in measles can often be prevented by regular 
cleansing of the lips, teeth and tongue — the toilet 
of the mouth, so important in typhoid fever. 

Not only during the acute stages of disease is 
hospital treatment required. The surroundings of 
many houses are such that convalescence is pro- 
longed and complete recovery rarely obtained. 
Fresh air, sunshine, suitable food, regular periods 
of rest and sleep, necessary in any disease, are 
especially so in ailments such as whooping-cough 
and measles, and in pneumonia and other dan- 
gerous infections. These essentials can be best 
provided in a convalescent home. 

Until such time, however, as adequate institu- 
tional accommodation becomes available, most 
cases of serious illness must be nursed at home. 
Fully-trained nurses on the staff of the Medical 

32 



Malnutrition 

Officer of Health should, under supervision, 
attend cases of bronchitis, pneumonia, measles, 
whooping-cough, ophthalmia and many other 
diseases. The visits must be paid as often as the 
condition of the patient demands, and as a rule 
not less than twice daily. 

Too long have children struggled unaided 
against the ravages of illnesses such as broncho- 
pneumonia. Worn to a shadow by long periods 
of confinement in an airless room, with parched 
lips crusted and cracked, with bodies bathed in 
perspiration under a heap of bed-clothing, it is 
surprising that any of the little patients recover. 
The result in most instances depends on efficient 
nursing. Each visit can be made the opportunity 
for giving simple instructions in the feeding and 
general management of the patient and in check- 
ing the spread of the disease. It should be 
possible for the nurses to obtain, as required, the 
loan of bedding, dressings, feeding-cup and other 
utensils. Fortunately, local authorities are em- 
powered to supply as well home helps to assist in 
the housework, to mind the children, and generally 
to relieve the overburdened mother. 

Combating malnutrition in the school. — In 
almost every instance the first step in the treat- 
ment of malnutrition should be to provide free 
meals at the school canteen. The next, to discover 
and attempt to remove the cause of the condition ; 
D 33 



The School Child 

this will generally entail a visit to the home, and 
advice to the parents with regard to feeding, rest 
and sleep. Any disease or defect found on medi- 
cal inspection must receive attention from an 
appropriate source. 

Education at an open-air school is one of the 
best methods of restoring health to the children 
who are ill-nourished. 



34 



CHAPTER II 
Dental Diseases 

Under this heading will be considered dental 
caries — a spreading infection of the tooth leading 
to its complete destruction ; pyorrhoea alveolaris — 
a chronic infection of the gums and the tissues 
around the teeth; irregularity and overcrowding 
of the teeth. 

Dental decay — Important in itself, on account 
of discomfort and difficulty in eating and loss of 
grinding surface, this is a source of danger to 
health mainly through the septic condition of the 
mouth usually associated with caries of the teeth. 
Poisons are formed and taken into the system both 
from the site of decay and from the decomposing 
food which collects around the painful tooth. 

Pyorrhoea may be present apart from any 
dental decay. It is an extremely serious affection, 
obscure in origin, insidious in progress, not easy 
to detect in the early stages, and as a rule difficult 
to cure. Although many years have passed since 
the relationship between pyorrhoea and pernicious 
anaemia was first pointed out, the significance of 

35 



The School Child 

the disease as a cause of ill-health is only now 
beginning to be recognised. 

Overcrowding of the teeth prevents thorough 
cleansing, and leads to the accumulation of food 
and tartar. The former rapidly undergoes decom- 
position, and the latter, spreading downwards, 
drives a wedge between the gum and the tooth, and 
opens up a way for infection. Pockets in which 
purulent matter collects are formed in the gums, 
and the pus overflows in the mouth. Secondary 
infection of the jaw and of the lymphatic glands 
in the neck may occur, but the chief injury to 
health is done by the circulation in the body of 
toxins absorbed from the teeth and gums. 
Anaemia, skin diseases, affections of the eye, and 
malnutrition follow in the train of oral sepsis. 

The systematic medical inspection of children 
has shown that decay of the teeth is terribly pre- 
valent, and that in many instances the mischief has 
obtained a firm hold by the time that the child first 
enters school. It has already been mentioned that 
about 80 per cent, of all children attending school 
require dental treatment, and in at least 25 per 
cent, of those entering school the teeth are to some 
extent already unsound. 

Various investigations which have been carried 
out seem to show that urban and rural children are 
almost equally affected, and that artificial feeding 
in infancy has but little influence on the prevalence 

3<3 



Dental Diseases 

of the disease. On the other hand, it is clear that 
the social condition of the children is an important 
factor ; decayed teeth are less common among those 
coming- from the homes of the poor, where prob- 
ably a coarser diet is given. 

When left untreated, the infection spreads until 
in early adult life not one sound tooth may be 
found. It is obvious, then, that prevention must 
be begun at an early stage, and be continued 
throughout life. 

Overcrowding and irregularity of teeth to an 
extent needing attention are found in about 5 per 
cent, of children, and usually require a consider- 
able expenditure of thought and time in treatment. 

Many reasons have been suggested to account 
for the prevalence of dental diseases. 

There is evidence to show that caries was un- 
common in the early history of man ; presumably, 
therefore, the cause lies among those factors 
making up civilisation. Lack of exercise of the 
jaws in early life, rickets, the infectious disorders 
of childhood, the excessive use of certain drugs, 
and probably inherited defects in the structure of 
the teeth may all be regarded as predisposing 
causes of dental decay. 

The immediate cause, however, is the destruc- 
tion of the enamel, the outer covering of the tooth, 
by acids formed by micro-organisms in the decom- 
posing fragments of food lying in the crevices of 

37 



The School Child 

the teeth. The soft, starchy substances, such as 
biscuits and cake, are particularly liable to cling to 
the teeth and undergo fermentation, whereas coarse 
fibrous material, meat, fish, and vegetables act as 
cleansers, and stimulate the flow of the saliva. 
Mouth-breathing also undoubtedly encourages the 
onset and progress of oral sepsis. 

Overcrowding and irregularity appear to be 
primarily due to insufficient development of the 
jaws, so that there is not enough space for the 
regular alignment of the teeth. The growth of the 
bones of the jaw may be retarded by want of mas- 
ticatory exercise in early life, or there may be 
structural defects of the palate associated with 
adenoids. 

How dental disease may be prevented. — 
One of the first steps in any preventive scheme 
must be an attempt to bring home to the parents 
the seriousness of the condition, the advantages of 
suitable diet, the value of the toothbrush, and the 
importance of early dental treatment. 

The interest of the mothers may be awakened 
by short illustrated addresses at maternity centres 
and schools for mothers, by the advice given by 
health visitors and school nurses during home 
visits to follow up dental defects or for any other 
purpose. A school dentist can often arrange to 
speak for a few minutes to the parents attending 
the school at the time of the routine dental inspec- 

38 



Dental Diseases 

tion, and to those bringing children to the school 
clinic for treatment. 

Education of the child may begin at an early 
age. In the nursery school, children two or three 
years old can be accustomed to the daily use of a 
toothbrush, and by the time of entry to an elemen- 
tary school many a child can with supervision clean 
the teeth. 

Toothbrush drill, with a separate labelled equip- 
ment of brush, powder and mug for each child, 
should form part of the daily instruction in every 
school. 

The teaching of the hygiene of the mouth 
should be given at frequent intervals in every class, 
in terms appropriate to the age of the children, 
arid should include toothbrush drill in dumb 
show. 

Dental inspection and treatment. — The ex- 
perience of the last nine years has proved con- 
clusively that every local authority should put into 
operation a complete scheme for dental inspection 
and treatment by whole-time dental surgeons, 
assisted by trained nurses. It is generally esti- 
mated that one whole-time dentist can examine and 
treqt about 2,500 children in a year. Treatment 
must largely be conservative, directed to the saving 
of teeth rather than to extraction. 

Treatment should be started concurrently with 
the onset of decay, and should, therefore, begin 

39 



The School Child 

at the nursery schools and child welfare centres, 
and be continued on entering school. 

Dental clinics, which have now been established 
by more than 150 Education Authorities, might 
reasonably form the nucleus of a comprehensive 
scheme for dealing with all children and young 
persons up to the age of 18 years. 

In the majority of areas the dental staff ap- 
pointed has not been sufficient to cope with the 
amount of disease, and it has therefore only 
been possible to inspect and treat children of 
certain age-groups, usually those in whom the 
permanent teeth were beginning to appear. 
Neither success nor economy can be expected from 
a scheme which is partial or badly organised ; much 
of the expenditure on conservative dentistry is 
likely to be wasted unless subsequently there are 
regular and frequent re-inspections. The entrants 
to school should receive prompt treatment, and 
should be examined again at least once every year 
during school life. 



40 



CHAPTER III 
Defects of Vision, Hearing and Speech 

Defects of Sight 

Defects of vision are a serious handicap to the 
child. Blindness is an intolerable burden to the 
individual and a heavy loss to the community. 

The teaching in elementary schools is largely 
visual, and for its reception there must be acuity 
of sight sufficient to follow without strain the 
writing on a blackboard and to read without diffi- 
culty well-printed books. With imperfect vision 
uncorrected a child cannot keep pace with its 
fellows. Although individual instruction and a 
favourable position near the blackboard may miti- 
gate some of the disadvantages of short sight, 
other common defects of vision cannot be met in 
a similar manner. With the expenditure of great 
physical and mental effort an intelligent child may 
overcome a few of the obstacles to education caused 
by errors of refraction, but the task imposed on the 
eyes and nervous system will soon be seen in sore 
eyelids, peering vision, headache, squint and other 
symptoms of eyestrain. 

41 



The School Child 

The more important diseases and defects of the 
eyes from which children may suffer are sore lids, 
inflammation of the inner surface of the eyelids 
and ulcers of the cornea, inflammation of the iris or 
of the lining membrane of the eyeball, and defects 
of refraction — short and long sight. On an 
average, it may be said that of all children needing 
treatment for the eyes, about 80 per cent, suffer 
from defects of vision and 20 per cent, from actual 
disease of the eye. 

The minor diseases of the eye — sore lids and 
the like — when not due to defects of vision, can 
often be traced to unfavourable home conditions. 
Dark, ill-ventilated rooms, overcrowding, infec- 
tious diseases, the very factors causing mal- 
nutrition, are at the root of many affections of the 
eye. 

Therefore, prevention must in the first place be 
directed to the removal of those dangers to eye and 
health embraced in the word insanitation — the 
demolition of unhealthy areas, the regular and 
thorough cleansing of streets and passages, the 
abolition of the conservancy system ; in short, com- 
plete and efficient Public Health administration. 

The more serious diseases, such as ulcers of 
the cornea and iritis, may result from neglect or 
mismanagement of an apparently trivial sore eye, 
or may follow measles, rheumatic fever, tuber- 
culosis or congenital venereal disease. Partial or 

42 



Defects of Sight 

total blindness dating from infancy is almost 
always due to purulent ophthalmia of the new-born 
— ophthalmia neonatorum. 

Many reasons have been given for the preva- 
lence of defective vision. In short sight the eye- 
ball is elongated. In some cases this condition 
may be inherited; in other instances work which 
entails stooping and congestion of the eyes seems 
to be the cause. The long eyeball is mainly a 
product of civilisation. 

In long sight the eyeball is slow in growth, and 
remains permanently too short; no satisfactory 
explanation is yet forthcoming to account for this 
failure of development. 

In astigmatism, the trouble is due to irregu- 
larity of the surface of the cornea, and as a rule 
it is found along with either an elongated or a 
shortened eye. 

Squint is a danger signal generally betokening 
failing sight in the squinting eye. It usually 
appears before school age, and unless prompt 
measures are taken the affected eye may become 
useless. 

To prevent corneal ulcers, arrangements should 
be made for the prompt and efficient treatment of 
the minor diseases of the eye, and the daily in- 
spection by a nurse of all children attending school. 
Diseases in their early stages can then be referred 
at once to a member of the school medical staff — 

43 



The School Child 

an ulcer rarely appears without the warning of a 
preliminary inflammation. 

While the influence of heredity as a cause of 
defective vision cannot be determined, it is appa- 
rent from the reports of School Medical Officers 
that measures to eliminate eyestrain are among the 
first steps that must be taken if the prevalence of 
defective eyesight is to be reduced. Attention 
must therefore be directed to the adequate light- 
ing of class-rooms, the use of suitable blackboards, 
books and desks, and the restriction of near work 
in the case of young children. The intimate rela- 
tionship which exists between ill-health and defec- 
tive vision points to the need of convalescent treat- 
ment after the more common infectious diseases of 
childhood, and to the urgent problem of mal- 
nutrition. 

Treatment. — Treatment of minor ailments of 
the eye can be carried out at a school clinic by a 
nurse acting under medical direction. With regular 
daily attendances extremely satisfactory results are 
likely to be obtained. Children suffering from 
corneal ulcers and serious affections of the eye 
should be seen by an ophthalmic surgeon or ad- 
mitted into an institution. 

Errors of refraction should be referred to an 
ophthalmic surgeon for correction by spectacles, 
and each case should again be examined by the 
specialist after the glasses have been provided. 

44 



Defects of Sight 

There are, however, two difficulties likely to be 
experienced after the treatment has been carried 
out. In the first place, the child may not wear 
the spectacles; secondly, they may presently be 
damaged or broken. The remedy lies in efficient 
supervision both in the school and at home. The 
daily visits to each class by a nurse will usually 
lead to regular use of the spectacles in school. As 
soon as the glasses are broken the child can be sent 
to the clinic. After treatment, every case of defec- 
tive vision should be seen again by the surgeon 
immediately signs of eyestrain appear, and under 
any circumstances within a year. 

In the majority of instances the errors of refrac- 
tion will be so far corrected that the child can com- 
pete with its neighbour on equal terms; but there 
will be a few children for whom the need of special 
facilities will arise. 

In urban districts it is generally possible to 
organise a special class in a conveniently situated 
school, and to place the children under the charge 
of a teacher trained in methods of oral instruction, 
thereby lessening the visual strain which attend- 
ance at an ordinary elementary school imposes. 
To such a class may be sent children suffering from 
squint, to undergo a course of exercise essential 
for restoring the functions of the failing eye. 
There is a further advantage, that by gather- 
ing together children whose vision is seriously 

45 



The School Child 

impaired it is more easy to arrange for frequent 
examinations by an ophthalmic surgeon and for 
operative treatment as necessity demands. 

A child unable through defect of vision to bene- 
fit by the instruction usually given at a public 
elementary school becomes eligible for admission 
to an institution for the blind. These residential 
schools give an intelligent child the opportunity of 
reading, writing, dancing, singing, and of becom- 
ing proficient at a trade, so that as young adults 
the scholars may be self-reliant and self-supporting 
members of the community. Further accommoda- 
tion is urgently needed for the blind, and much 
more might be attempted in the way of extending 
the scope of teaching in manual work. Gardening, 
poultry^-keeping, and some kinds of dairy and 
farm work are useful occupations for enlarging 
wege-earning capacity, and are less monotonous 
than chair-caning, basket- and mat-making. 

Diseases of the Ear and Defects of Hearing 

Waves of sound striking upon the drum of the 
ear are conducted by a chain of small bones across 
the chamber of the middle ear to the membranous 
wall of the internal ear, from which impulses pass 
to the brain. The middle ear is connected with the 
throat by a channel — the Eustachian tube — along 
which air can pass. Obstruction of this tube immo- 

46 



Defects of Hearing 

bilises the drum and interferes with the conduction 
of sound to the inner ear. 

The throat is often the site of acute infection, 
and the inflammation is apt to spread up the 
Eustachian tube to the middle ear. 

An abcess forming in this part of the ear gene- 
rally bursts through the drum, and the condition 
known as ear discharge follows. 

About 3 per cent, of the children attending 
public elementary schools suffer from some form 
of disease or defect of the ear. 

Deafness, is a serious handicap both during 
school life and in after-years. It deprives a child 
of most of the advantages to be derived from oral 
teaching, and even when present in a slight degree 
leads to dullness and inattention. 

When the child leaves school, deafness bars the 
way to many employments, and unless special in- 
struction is provided a deaf person may become a 
burden on the State. 

The discharge often associated with disease of 
the middle ear renders a child a nuisance, and 
frequently a danger to other members of the class. 

The causes of deafness in children are mainly 
two. The defect may be congenital — the 
infant is completely deaf from the time of birth, 
and as a consequence does not learn to speak — a 
deaf-mute. In the majority of instances, however, 
deafness is due tp disease of the middle ear, gener- 

47 



The School Child 

ally set up by one of the acute infectious diseases 
of childhood or by continued obstruction of the 
Eustachian tubes. 

Among the infectious diseases, measles, scarlet 
fever, diphtheria and colds in the head are chiefly 
important in this connection. Septic conditions of 
the mouth and mouth-breathing may be the origin 
of an acute tonsillitis and middle-ear disease. 

Enlargement of the tonsils and adenoids brings 
about deafness by obstructing the passage of air 
along the Eustachian tubes to the middle ear. The 
fact that removal of enlarged tonsils often leads to 
the cessation of ear discharge seems to show that 
suppuration in the middle ear may be kept active 
by an unhealthy state of the throat. 

Progressive deafness occurring in early adult 
life will, on investigation, frequently be found 
attributable to enlargement of the tonsils in child- 
hood. Disease of the middle ear unaccompanied 
by ear discharge is apt to be overlooked unless a 
careful examination is carried out and the drum 
of the ear inspected in every case of deafness, how- 
ever slight. Defect or disease of the nose, in that 
it leads to mouth-breathing, may give rise to deaf- 
ness and general ill-health. 

Prevention and Cure. — It should be widely 
known that deafness is to a large extent preventable. 

A carefully organised campaign to diminish the 
prevalence of infectious diseases, particularly 

48 



Defects of Hearing 

measles and scarlet fever, prompt removal to 
hospital when the home circumstances are un- 
favourable, and the liberal provision of home nurs- 
ing, all directly tend to reduction of middle-ear 
disease and the deafness it causes. 

It is hardly possible to overestimate the im- 
portance of efficient nursing during the occurrence 
of illness generally, and especially in the infectious 
diseases. Thorough cleansing of the mouth, nose, 
and throat is so essential that in measles and 
pneumonia dangerous respiratory complications 
can often be avoided by mouth toilette alone. 

A serious attempt should be made to bring 
home to parents the risks attending a cold in the 
head, an acute infectious disease transmitted from 
person to person by the act of coughing, sneezing, 
and the use in common of feeding utensils. The 
germs causing the disease generally first lodge in 
the throat and then spread up the back of the nose 
and along the Eustachian tube to the ear, so that 
sore throat, difficulty in breathing through the 
nose, and deafness are experienced. Later, hoarse- 
ness and bronchitis are signs that the disease has 
invaded the lungs. 

Fortunately, there are means available whereby 
a cold in the head can be prevented or checked 
in the early stages. Oral and nasal hygiene should 
be part of the daily life of every person. Gargling 
the throat and washing out the nose are as useful 

E 49 



The School Child 

in keeping the body healthy as cleaning the teeth, 
and during the spring and autumn, when colds are 
common, should never be neglected. The infection 
can often be aborted in the beginning by the 
frequent douching of the nose. 

Persons suffering from a cold should remain at 
home, and should, on coughing and sneezing, 
always hold a handkerchief before the face. 

If it is necessary to mingle with the public, a 
mask should be worn. Knives, forks, spoons, and 
cups should be immersed in boiling water, since 
the experience of institutions shows that infection 
is readily spread by articles in common use. 

The proper development of the nose is depen- 
dent on its regular use in breathing. Disease leads 
to accumulation of mucus and predisposes to in- 
fection. 

Every child, on entry into school, should be 
medically examined ; those found to be deaf should 
be referred for treatment by an aural specialist. 

Slight deafness can, at times, be cured by 
pocket-handkerchief drill ; in other cases removal 
of the tonsils and adenoids may be needed. 

Middle-ear disease, with discharge, will fre- 
quently clear up under daily syringing by a nurse 
acting under medical supervision. 

In a few instances an operation on the ear may 
be necessary. 

.Whatever treatment is adopted, regular per- 
50 



Defects of Hearing 

sistent following up is essential to observe the 
progress made and to watch for signs of relapse. 

Education of the Deaf. — The need for 
special provision for the education of the deaf is 
urgent in proportion to the degree of deafness. 

Children who are slightly affected, if allowed 
to sit in front of the class, may be taught in 
ordinary elementary schools. More advanced 
cases among those partially deaf can receive in- 
struction in special classes^, under the charge of 
teachers trained in the methods to be employed, 
while those completely deaf, including deaf-mutes, 
are suitable for admission to institutions. 

Education of the deaf is directed chiefly towards 
the attainment of two objects — the cultivation and 
restoration of speech, and the acquirement of a 
trade. Without these the outlook of a deaf child 
is almost without hope. Promising results are 
shown by various schools for the deaf ; on leaving, 
an. intelligent child can usually obtain suitable 
employment, and a large proportion become highly 
skilled workmen. 

Inquiry into the after-history of the patients 
generally supports the assertion that speech is 
retained and the aptitude for careful work persists. 

Money spent in the education of the deaf is 
certainly a sound investment. 

It would be cheaper, however, to prevent the 
occurrence of the diseases which lead to the defect. 

SI 



The School Child 



Defects of Speech 

Stammering is an important defect of speech 
found in about i per cent, of school children. 
Although the proportion of stammerers to those 
with normal speech is not large, yet the condition 
is a very real handicap to the individual, and likely 
to interefere with the career of the child in school 
and in after-life. 

Apart from stammering, some defect in articu- 
lation is present in from 2 to 3 per cent, of children 
medically inspected. There is, however, no evi- 
dence to what extent defects of speech among those 
entering school develop into stammering in later 
years. 

The stammerer is usually nervous, sensitive, 
self-conscious — peculiarities which aggravate the 
disturbance of speech. More common in boys than 
in girls, the defect is generally established before 
school age. For the causes, therefore, search must 
be made into the family history of the parents and 
the surroundings of early childhood. While it is 
possible that a tendency to stammer may be in- 
herited, there is the important factor that a normal 
child learns to speak by tedious attempts at the 
imitation of sound, and may consequently acquire 
the defect by association with a parent similarly 
affected. The experience of the War has demon- 

52 



Defects of Speech 

strated the internal origin of shell-shock, of which 
stammering is a frequent symptom, and a close 
connection with the repression of fear. It is thus 
more than likely that stammering is almost entirely 
due to a disordered mental condition. It remains 
true, nevertheless, that the children are often ill- 
nourished, anaemic, tired, and suffer from some 
marked physical defect — enlarged tonsils, adenoids, 
defective vision, deformity of the jaw or chest. 

In the present uncertainty of the exact causes 
of stammering, prevention must largely aim at the 
treatment of the early defects of articulation by 
breathing and vocal exercises, reading aloud, and 
the cultivation of self-reliance. 

During the past four or five years considerable 
progress has been made in the methods adopted to 
educate children who stammer, but only in a few 
areas has a well-organised and complete scheme 
been initiated. Broadly speaking, the measures 
to be taken in any district should follow four 
lines. 

In the first place, the affected children must be 
discovered by systematic medical inspection of the 
entrants and other age^groups. Individual cases 
should be referred to the School Medical Officer 
by the school nurses and teachers. Every stam- 
merer must be carefully examined to discover the 
extent of the defect and the possible presence of any 
other abnormality. 



The School Child 

Secondly, the general health should be im- 
proved by ample food, fresh air and rest, and treat- 
ment provided for defects such as enlarged tonsils 
and adenoids. 

Thirdly, special classes for stammerers should 
be established in the ordinary elementary schools, 
under the direction of a teacher qualified for the 
work. It is essential to attempt to secure one in 
whom the children will have confidence; whose 
efforts will be to implant or restore self-control in 
the patient. On the selection of the teacher de- 
pends the success of the class. 

It is usual to limit the class to about twelve 
children, and to insist on a period of at least six 
weeks' attendance. There are, as a rule, two 
sessions daily, each of two hours' duration. Half 
of each session should be given up to special in- 
struction — breathing and vocal exercises ; the 
remainder to ordinary school work and manual 
work in the open air. 

The results of the treatment are soon apparent. 
At the end of six weeks nearly all the children will 
have made remarkable progress, both in reading 
aloud and in speech. The improvement in speak- 
ing is frequently beyond belief. 

Finally, on returning to the ordinary school, 
it is necessary that each child should be persis- 
tently followed up to supervise the home conditions 
and to watch for signs of a relapse. Even without 

54 



Defects of Speech 

after-care, about half the cases will remain per- 
manently cured. 

In some localities revision classes are held so 
that every child, at any time in attendance at a 
special class, is assured of at least three weeks' 
tuition each year. Re-examination should be 
carried out by the School Medical Officer at in- 
tervals of about six months, and a record card kept 
in each instance. 

It is probable that too little effort has been made 
to arouse the interest and seek the assistance of the 
parents. In some classes a preliminary period 
of fourteen days' complete silence is prescribed, 
hut to secure this is almost impossible unless the 
parents enter heartily into the attempt which is 
being made to effect a cure, and later try to en- 
force at home the deliberate speech and peaceful 
surroundings which may make the recovery 
permanent. 



55 



CHAPTER IV 
Heart and Lung Disease 

Diseases of the Heart 

The membranes lining the heart, and those cover- 
ing its surface, are liable to acute inflammation, 
particularly during the early years of life. The 
detection of the disease at the time of its occurrence 
is by no means easy. On the one hand, the 
severity of the primary illness may obscure the 
symptoms; on the other hand, constitutional dis- 
turbance may be so mild that the onset of the 
disease passes unnoticed. 

In either case, medical inspection during school 
age may first reveal the presence of damage to the 
heart. The inflammation may be most marked in 
the valves, and it is here that the permanent effect 
of the disease soon becomes apparent in the failure 
of the valves to close the various chambers of the 
heart. A prolonged period of complete rest in the 
early stages of the disease may check the progress 
of the inflammation, and prevent the thickening 
and destruction of the valve. It is extremely 
important, therefore, that the affection should be 
recognised in the beginning. 

56 



Diseases of the Heart 

Definite signs of valvular disease of the heart 
are not common in school children. Only about i 
per cent, of those medically inspected show evi- 
dence of organic disease; but there is reason to 
think that the mischief is more frequent among 
the older children, and it should not be impossible 
to devise measures of school hygiene whereby the 
prevalence of the disease may be diminished. 

Apart from organic diseases, functional dis- 
orders of the heart — irregular action and the like — 
are found in some 2 per cent, of school children, 
and are beginning to attract attention in view of 
the possibility that the more serious defect may 
follow. 

The membranes of the heart may become in- 
fected during acute illnesses such as rheumatic 
fever, chorea, scarlet fever, and pneumonia. By 
far the most potent of them is rheumatic fever; 
but the frequency with which a history of past 
illness is lacking when organic disease is dis- 
covered supports the contention that for the 
beginnings of the disease search must be made 
among the apparently trivial ailments of childhood. 

Recurring attacks of tonsillitis, "growing 
pains," with bouts of feverishness and headache, 
are tokens of subacute rheumatism, which is un- 
doubtedly one of the most active agents in the 
production of endocarditis — inflammation of the 
lining of the heart. Mild and transient signs of 

57 



The School Child 

St. Vitus's dance, unsteadiness in grasping objects, 
slight twitching of the face and limbs call for an 
examination of the heart. 

In a small proportion of the cases heart disease 
dates from birth, and is due to defects in develop- 
ment. In some instances the muscle of the heart 
may be at fault, the result, possibly, of diphtheria 
or other infection. 

Functional disorders of the heart, such as ir- 
regularity, and palpitation under excitement, are 
probably often due to an inherited instability of 
the nervous mechanism, and are of little or no 
detriment to the future health of the child. 

Very careful examination, at times, is needed 
to differentiate between the minor degrees of 
organic disease and functional abnormalities, and 
in some instances it is only after repeated exami- 
nation that a decision can be made. 

For the prevention of endocarditis there must be 
an attempt to diminish the prevalence of rheumatic 
fever. 

Unfortunately, little is known concerning the 
cause of this disease. Exposure to damp, wearing 
wet clothes or thin footgear, are thought to pre- 
dispose to infection ; certainly the existence of an 
unhealthy condition of the nose and throat, and 
particularly enlarged tonsils, seems to be a factor 
of importance. 

Early recognition of the occurrence of subacute 
58 



Diseases of the Heart 

rheumatism is of great value, and to this end a 
nurse should daily visit each class in school, 
to observe the condition of those present, and 
to discover the reasons which lead to irre- 
gular attendance. The temperature of children 
suspected to be ailing should be taken, and a 
general supervision of minor maladies enforced. 
Every department should possess facilities for the 
drying of clothing, and generally a close watch 
should be kept over the ventilation and manage- 
ment of the cloak-room, which should be sufficiently 
large to allow of the hanging of each garment 
without overlapping. Every school should possess 
a supply of clothing and slippers for those who 
have to remove wet garments. 

Enlarged tonsils, "growing pains," and chorea 
should receive adequate treatment, and in every 
case the home conditions should be the subject of 
investigation. The possibility of a damp, ill- 
ventilated bedroom should be borne in mind. The 
parents should be encouraged to pay attention 
to the importance of suitable clothing and footwear 
for the child, and to other details of personal 
hygiene. 

Children with non-progressive organic disease 
of slight extent, or with functional disorders asso- 
ciated with some degree of ill-health, can generally 
attend an ordinary elementary school, or when 
practicable an open-air school. 

59 



The School Child 

Physical exercise may, as a rule, be permitted, 
due care being taken to watch for any appearance 
of heartstrain. 

When the disease is of moderate extent, by far 
the best course is to provide institutional treatment 
in a residential school ; in this way it is possible 
to arrange for rest in bed, graduated exercises, and 
constant medical supervision. The child can be 
taught a suitable trade which will not impose a 
strain on the heart. 

In advanced cases, and those in which the 
damage is progressive, children left at home are 
liable to drift into the state of incurable invalids, 
never able to earn a wage or afford medical attention. 
For most of these the quiet, well-regulated life of an 
institution is required. Under skilled direction 
and comfortable surroundings they may take an 
interest in life, and even do a considerable amount 
of useful work. 



Diseases of the Lung 

Bronchitis, broncho-pneumonia, and tubercu- 
losis are the three lung diseases most commonly 
found in children of school age; the first is by 
far the most prevalent, and possibly the most 
important. 

Bronchitis. — Of children entering school, 
60 



Diseases of the Lung 

about 5 per cent, suffer from bronchitis, the signi- 
ficance of which, as a cause of ill-health, has hardly 
yet begun to be appreciated. In England and 
Wales during 19 17 some 8,000 deaths of children 
under 15 years of age were stated to be due to 
bronchitis, and it is reasonable to assume that per- 
manent damage was done to many that recovered. 

The relationship between malnutrition and 
bronchitis has already been pointed out, but be- 
yond this, bronchitis unquestionably prepares the 
way for more serious lung diseases — bronchiec- 
tasis, broncho-pneumonia, and tuberculosis. 

Bronchitis may be considered a chronic infec- 
tion of the larger air-passages by micro-organisms 
of low virulence. In many instances the starting 
point is an unhealthy state of the mouth, nose, or 
throat, decayed teeth, adenoids, or enlarged 
tonsils. The acute infections of childhood, par- 
ticularly measles and whooping-cough, are rightly 
blamed for the beginning of bronchitis ; but in a 
large proportion of the cases there is in addition 
the influence of insanitary conditions of the 
house, lack of sunlight and of air, ill-ventilated 
bedrooms, overcrowding, and want of personal 
cleanliness. 

Pulmonary tuberculosis. — The extent to 
which this disease occurs in children has been a 
matter of much controversy. Some consider it 
quite common, while others think it extremely rare. 

61 



The School Child 

The explanation of these diametrically opposite 
views may be found in the fact that children are 
liable to an infection of the lungs producing phy- 
sical signs closely resembling those of tuberculosis, 
but due to germs other than the tubercle bacillus. 
This disease may be regarded as chronic broncho- 
pneumonia, sometimes beginning in an acute 
illness with feverishness and rapid respirations, 
while in other cases the onset is indefinite and un- 
noticed. The condition may persist for several 
months and eventually disappear, or the infection 
in the lungs may spread and bring about the death 
of the child. 

Of the causes of this disease practically 
nothing is known; it is more common in the slum 
child than in one coming from a clean, well- 
managed home. More than one member of a 
family may be affected, and the disease may be 
found in those under school age. 

Pulmonary tuberculosis is rare in children, and" 
especially rare in those attending infant depart- 
ments. In every district, however, adequate 
arrangements should be made to cope with the 
whole problem of tuberculosis. 

Fortunately, there is now in most areas the 
machinery whereby ailing children can be referred 
to specialists; but facilities for treatment in sana- 
toria or open-air schools are totally insufficient. 

To the cause of pulmonary tuberculosis it is 
62 



Diseases of the Lung 

hardly necessary to refer. The invasion of the 
lung by the tubercle bacillus is usually aided by 
unhealthy home surroundings. A recent attack 
of measles or other illness may have reduced the 
resistance of the body. The immediate cause, as 
a rule, is intimate contact with a consumptive 
person. 

Prevention. — The prevention of lung diseases 
will be found first in general measures directed 
towards improving the health of the child popu- 
lation. The closing of insanitary areas, the pre- 
vention and postponement of infectious diseases, 
adequate and prompt treatment of defects of the 
teeth, nose, and throat, hospital accommodation 
and home nursing for serious illnesses, light and 
airy schools and ample playgrounds — all these will 
lead to the reduction of respiratory disorders. An 
increasing knowledge of the value of cleanliness 
and fresh air and of the danger of neglecting minor 
ailments will do much to diminish the prevalence 
of such diseases, which now cause some 50,000 
deaths each year. 

Pulmonary tuberculosis is mainly spread by 
patients in an advanced stage of the disease, and 
for this reason it is essential that institutions suffi- 
cient to meet the demands of the locality should 
be available. The housing should be such that 
a careful consumptive can live at home without in- 
fecting other members of the family. 

63 



The School Child 

The treatment, in the first place, should be 
directed towards the amelioration of the home 
conditions, and advice should be given to the 
mother with regard to suitable food, clothing, and 
sleeping accommodation. 

Next comes the provision of institutional treat- 
ment for the child. Every case of tuberculosis, 
chronic broncho-pneumonia, and the more persis- 
tent and marked instances of bronchitis require 
the diet, rest, and healthy living provided in a 
sanatorium or residential open-air school. Ex- 
perience of the results there obtained affords 
convincing proof of the value of open-air life in 
diseases of the respiratory system. 

Expenditure on convalescent homes, schools for 
recovery, and open-air schools is one of the most 
remunerative investments that a local authority can 
make. Pulmonary tuberculosis and other infections 
of the lung in children readily respond to treatment, 
and under favourable home circumstances do not, 
as a rule, recur, so that years of ill-health or often 
premature death can be averted by prompt attention 
in childhood. 

In less serious instances of bronchitis children 
may attend open-air day schools, or open-air classes 
at an ordinary school. 

Lastly, a child, once found to be suffering from 
these diseases should, in no circumstances, be lost 
sight of. Persistent and regular following up by 

64 



Diseases of the Lung 

nurses is necessary to ensure that the routine of 
open-air life is not forgotten in the surroundings 
and example of the home. 

Unless there is evidence that the child is so 
infectious as to be a danger to others, exclusion 
from the school should not be enforced. 



65 



CHAPTER V 

Minor Ailments 

Under this term will be considered numerous 
diseases generally regarded by parents as too trivial 
to be worth treatment. Like the sore eyelids, in- 
flammation of the surface of the eye, conjunctivitis, 
ulcers of the cornea, and ear discharge, that have 
been reviewed in Chapter III., chilblains, cuts and 
sores, and contagious diseases such as impetigo, 
ringworm, itch, and pediculosis, far from being 
trivial, are of extreme importance to the health and 
comfort of a child. 

Certain of these ailments may, as we have seen, 
be the beginnings of serious permanent damage to 
sight or hearing. In other instances there is grave; 
risk that the disease may spread throughout the 
class or school. In every case the education of th6 
child is likely to suffer, either through physical 
disability and discomfort, or by exclusion from 
school on account of contagious disease. 

Ringworm. — Of this disease there are two types 
■ — that affecting the skin and that usually attacking 
the hairy scalp., 

66 



Minor Ailments 

The former is generally of bovine origin, and 
is particularly easy to cure. The red rings of the 
fungus can be destroyed by two or three daily 
applications of iodine, and exclusion from school 
while treatment is taking place is unnecessary. 

Ringworm of the scalp is a much more serious 
infection. It is almost always derived from a pre- 
existing human case, and a child under school age 
may be the source. 

The prevalence of scalp ringworm varies greatly 
in different localities. In some districts nearly 5 
per cent, of all school children may be infected, 
while in other areas there may be less than i per 
cent. Infants' departments provide by far the 
largest number of cases, for after the eighth year 
the hair begins to show increasing resistance to the 
parasite. 

The disease usually takes the form of areas of 
scurf through which short stumps of brittle hairs 
protrude. Owing to the fact that the fungus pene- 
trates the hair and passes down into the follicle, 
the infection is notoriously resistant to the appli- 
cation of antiseptics. 

The prevention is more simple than the cure. 
Every child suffering from scalp ringworm is a 
focus of infection. Caps, towels, brushes, shawls, 
and the dust of class-rooms are the main channels 
by means of which the spores of the fungus are 
conveyed. 

67 



The School Child 

The head of every school child should be care- 
fully examined at least once a month by a nurse 
instructed in the method to be adopted. On the 
discovery of an instance of the disease a very 
thorough inspection of each scalp in the school 
should be made every week for three months. A 
pocket lens should be used in the examination of 
suspected cases. 

Children suffering from ringworm of the scalp 
must be excluded from school until a re-admission 
notice has been issued by the Medical Officer. A 
home visit should be made, particularly for the 
purpose of discovering disease in those under 
school age, and to arrange for disinfection. 

Treatment may take the form of the application 
of various chemicals or the use of X-rays. In the 
former it is essential that the affected area should 
be shaved at least twice a week, and that no water 
should be applied to the scalp. The X-ray treat- 
ment, by causing the hair to fall out, frees the 
follicles from infection, and is doubtless the most 
rapid and most certain method to employ. With- 
out the use of X-rays the disease may persist for 
several months or even years, and the loss of edu- 
cation will be a very serious matter for the child. 
To meet this, in urban areas the prevalence of ring- 
worm may justify the establishment of a special 
class for those excluded from ordinary elementary 
schools. This procedure has the advantage that 

68 



Minor Ailments 

the children are being educated, and at the same 
time are under treatment and supervision. 

Scabies. — Itch, like ringworm of the skin, is 
an ailment of which the treatment is comparatively 
simple, and can be carried out by a nurse acting 
under medical direction. It is, however, a disease 
causing considerable discomfort and, at times, in- 
tolerable itching. Scabies is due to the invasion of 
the skin by the itch parasite. The female burrows 
into the skin and there deposits eggs, while the 
male remains on the surface or in the clothing. 
The infection has become, owing to the War, much 
more prevalent than formerly, but even in pre-war 
times it was the cause of much loss of attendance, 
mainly because in few areas have systematic 
schemes been provided to deal with the problem. 

The first step in prevention must be the detec- 
tion of the disease, and the public elementary 
schools afford a convenient starting-point for in- 
quiry. Every child in a school should be examined 
by a trained nurse at intervals of not more than a 
month. Children suspected to be suffering from 
itch should be referred to a member of the school 
medical staff. Those actually affected should be 
excluded and followed up to their homes in order 
that arrangements may be made for treatment. 
Careful inquiries should be conducted into the pos- 
sibility of infection in other members of the family. 
Thorough disinfection of the clothing and bedding 

69 



The School Child 

must be carried out if a recurrence is to be avoided, 
and where in a house several persons are involved, 
disinfection may have to be repeated. 

To obtain treatment the child can attend at a 
school clinic or other centre for baths and inunc- 
tion, or can be admitted into hospital. Experience 
has shown it to be almost useless to expect that 
scabies will be cured in a reasonable time if the 
treatment is left to the parents. Without the sys- 
tematic routine in operation at a school clinic or 
institution, it is common to find children uncured 
after many months' absence from school. 

The details of the treatment are simple. On 
arrival at the centre the child is given a hot bath 
and an attempt is made to expose the burrows by 
vigorous lathering with a soft brush. After care- 
ful drying of the skin, sulphur ointment is rubbed 
all over the body and particularly on the areas most 
affected. While bathing has been taking place the 
clothing should have been disinfected, washed, and 
dried. This routine is repeated daily, and in most 
instances three applications are sufficient to effect 
a cure. On the first day of attendance, and again 
in three or four days, the bedding must be removed 
from the home for sterilisation by steam. The 
facilities of a laundry and disinfecting apparatus 
are most easily obtained by using premises at a 
hospital or similar institution as a centre. 

The chief difficulty likely to be experienced is 
70 



Minor Ailments 

the irregular attendance of the children. Persistent 
following up may obviate this to some extent, but 
in a proportion of the cases arrangements will have 
to be made for admission to a hospital, or for 
treatment in the home. The former is the most 
satisfactory method. 

Infestation with vermin. — One of the most 
noticeable results achieved by school medical 
inspection has been a marked improvement in the 
state of cleanliness of the children. It is rare now, 
among those attending school, to find conditions 
such as were frequently discovered ten years ago. 
But further progress is needed. Even now about 15 
per cent, of all children systematically examined 
have verminous heads, but as it is usual to acquaint 
parents with the time of the medical inspection of 
their children, the proportion of dirty heads among 
all children in school is probably considerably in 
excess of the figures mentioned. 

Though dirt and disease are old associates, at 
the present day it should be hardly necessary to 
refer to the injurious effects on health of the pre- 
sence of vermin. 

Investigation carried out during the War has 
shown that trench fever, and possibly other illnesses 
which may become prevalent in England, are trans- 
mitted by lice. More than ever, therefore, is it 
necessary to keep in operation carefully planned 
schemes to stamp out uncleanliness. 

71 



The School Child 

Every child in school should be examined by a 
nurse at least once a month. Those found to be 
verminous must be followed up in order that in- 
struction and warning may be given to the mother 
and inquiry made into the sanitary condition of the 
house. It is common to find that in some of the 
cases re-infection comes from children under school 
age, young adults, and even from the parents. 

Legislation is urgently needed to deal with 
verminous persons other than children. 

The sanitary defects in the house should be 
remedied, and in some instances general cleansing 
of the premises and disinfection of bedding will be 
required. Each child found to be verminous should 
be re-examined in school within a week from the 
date of the first inspection, and unless the condi- 
tion has been remedied a notice should be served 
on the parents, and the child treated at a cleansing 
centre. 

School Medical Officers have clearly proved that 
success lies in the frequent survey of all children 
and in the removal of insanitation in the home, for 
it is notorious that in every school there are certain 
children, generally those from slum areas, who 
act as sources of infection. 

The ideal, undoubtedly, is that every child 
should attend school clean and free from vermin ; 
but until this is realised some attention must be 
given to the prevention of infection in schools. 

72 



Minor Ailments 

The hair of boys should be kept short, and that 
of the girls should be tied in a coil at the back of 
the head, unless the parents prefer that it should 
be cut. Overcrowding in the class-rooms and the 
indiscriminate heaping together of clothing in 
cloak-rooms increase the opportunities for the trans- 
mission of lice. 

The standard of cleanliness maintained in a 
school is largely in the hands of the teachers, who 
can do much good by example and by simple class 
teaching in the elements of personal hygiene. 

Further facilities are urgently needed so that 
every child can wash before each school session, 
and have at least a weekly bath on the school 
premises. 

The abolition of the common towel has too long 
been delayed. When two or three hundred children 
use the same towel for a week, the spread of various 
contagious diseases needs little further explanation. 

Injuries. — Some injuries and accidents can well 
be included in the scope of the activities of a school 
clinic. Slight burns and scalds, foreign bodies in 
the eye, ear, or nose, bruises, abrasions, and the 
like, although rightly regarded as minor ailments, 
are often the beginnings of disease. 

A successful campaign directed to the early de- 
tection and prompt treatment of minor ailments is 
largely dependent on the provision of an adequate 
staff of school nurses. In considering the question, 

73 



The School Child 

factors such as the social status of the children, 
the amount of travelling entailed in visiting the 
schools, and the character of the homes must have 
due weight ; but, speaking generally, it may be said 
that for all health purposes the whole-time service 
of one nurse will be required for each thousand 
children under 14 years of age. There will, how- 
ever, soon be experienced a remunerative return on 
the expenditure incurred, an improvement in health 
and in school attendance. 

School attendance and illness. — Before pass- 
ing from the diseases and ailments that have been 
considered in this and the preceding chapters, 
something may be said about school attendance, 
especially as affected by illness. 

Regularity of attendance depends, of course, not 
only on freedom from illness, but also on comfort- 
able home circumstances, on the children not 
having to walk an unreasonable distance, and on 
the absence of inclement weather. In this connec- 
tion it may be noted that the attitude of parents 
towards compulsory education has undergone con- 
siderable change in recent years, and there is now 
springing up a wider appreciation of the benefits 
to be derived from attendance at the public ele- 
mentary schools. 

In the beginning the activities of the School 
Medical Service, inevitably leading to loss of at- 
tendance through the exclusion of ailing children 

74 



Minor Ailments 

and those suifering from or in contact with infec- 
tious disease, were somewhat misunderstood. After 
a few years, however, it began to be apparent that 
parents were becoming aware of the value of 
medical inspection and treatment. As time went on, 
the usefulness of special schools, open-air classes, 
and organised games came to be more generally- 
known, so that at the present day there is a more 
kindly feeling towards the system of compulsory 
education in force in the country. 

The vast majority of children absent from school 
are kept at home on alleged medical grounds. 
Serious illness probably accounts for only a small 
proportion of the absentees; the remainder consist 
of children suffering from minor ailments, coughs, 
colds, and bouts of feverishness. 

In a few instances reasons other than those of 
health are given for non-attendance at school, the 
more common being wet clothing, the lack of foot- 
wear, and trouble in the home. 

The exclusion of '♦ contacts." — It is aften 
stated that one of the main causes of loss of attend- 
ance is the system by which children in contact 
with infectious diseases are excluded from school. 
The scheme generally adopted provides that a child 
living in a house in which there is infectious disease 
is excluded for a period rather longer than the time 
taken for the disease to incubate. In various locali- 
ties, however, modifications are in force. In some 

75 



The School Child 

areas only those contacts thought to be susceptible 
to infection are kept from school, while in other 
districts children in the senior departments are 
excluded less rigidly than the infants. 

The system of the exclusion of contacts is 
mainly directed at preventing a child who has been 
exposed to infection from falling ill in school. 

Opponents of the system urge that children ex- 
cluded from school are at least as likely to spread 
infection while playing in the streets or congre- 
gating in places of entertainment, and there would 
seem to be reason in this view. In rural areas, how- 
ever, opportunities for meeting, except on school 
premises, are considerably less common than in 
towns. 

That scarlet fever, measles, and other infectious 
illnesses have frequently been spread by the pre- 
sence in a school class of children sickening for 
the diseases, cannot be denied. On the other hand, 
there is little evidence that iri the common diseases 
of childhood contacts convey infection in their 
clothing. 

While it is obviously necessary to keep from 
school such children as are in an infectious con- 
dition, it would seem that the question of excluding 
those living in an infected house should be re- 
considered. 

If children are examined every day by a trained 
nurse acting under medical supervision, and a close 

76 



Minor Ailments 

watch is kept for the onset of illness, it is probable 
that contacts can be allowed in school without risk 
to their fellows. 

In one county borough, with an industrial 
population of 100,000 persons, the following 
scheme has been in operation for about six months : 
The town is divided into twenty areas, in each of 
which there is school accommodation for approxi- 
mately 1,000 children. A trained nurse is placed 
in charge of each area and acts as health visitor 
and school nurse; in fact, carries out all health 
work for which a woman is specially qualified. 

During each morning the nurse visits every 
school in her area. She examines the attendance 
register, and makes out a card for each child ab- 
sent for more than two days. Every class room is 
entered in turn and the teacher is asked to point 
out any child concerning whose condition an 
opinion is needed. Each child in the class is then 
quickly surveyed, particular attention being paid 
to those who are in contact with infectious disease 
at home. Minor ailments and other defects thus 
brought to light are treated in school or referred to 
a medical practitioner or school clinic. A child 
ailing or feverish is sent home. 

This daily visit is often the occasion of advice 
respecting the ventilation, warming, or cleanliness 
of the class-rooms. 

At intervals of about a month a careful ex- 



The School Child 

amination of each child is made with reference to 
the state of cleanhness and freedom from contagion. 

The cards on which are names of absentees are 
distributed among the nurses in whose areas the 
children live, and a home visit is made to determine 
the nature of the alleged illness, and the need for 
medical advice and treatment. 

Immediately the plan of daily visiting and in- 
spection was started there was apparent an 
improvement in the appearance of the children; 
they came to school cleaner in person and more 
tidy in clothing. The attendance rose almost at 
once about 6 per cent., and parents began to avail 
themselves of the presence of the nurse in school 
to send there for advice and treatment children who 
otherwise would have been kept at home. 

By giving each nurse a comparatively small 
district, she soon gets to be known to the inhabit- 
ants, and frequent home visiting becomes possible. 

In localities where home visiting is persistently 
carried out and a real attempt is made to assist 
parents when sickness occurs or insanitation is 
present, the nurse comes to be regarded as a friend 
to whom appeal is made in time of need. 

By measures such as these the beginnings of 
disease will be discovered, the spread of infection 
will be checked, and the average man and woman 
will be enlisted in a national health campaign. 

78 



CHAPTER VI 
The Cripple-Child 

Until recent years a cripple was understood to be 
a lame person, and those suffering from defects of 
the body and upper limbs were not looked upon as 
cripples unless lameness was also present. A wider 
meaning has, however, been given to the word, 
which now includes children who are abnormal on 
account of disease or defect of bones or joints, 
those suffering from paralysis, and those in whom 
there is serious disease of the heart. Logically, all 
physical defects, deafness, blindness, and the like, 
rendering a child unfit for education in an ordinary 
school or for participation in physical exercises 
and games, might be regarded as causes of crip- 
pling; but in considering the welfare of cripple- 
children it will be convenient to confine our atten- 
tion to those who, through physical defect, are 
unable to lead an active life. 

The ranks of the unemployed and destitute are 
still recruited from children mentally or physically 
defective. 

The cripple-child is generally irregular in at- 
tendance at school, and in some cases receives no 

79 



The School Child 

education at all. On leaving school, cast into the 
world without a trade, shut out from unskilled 
labour through physical inability to compete with 
the able-bodied, he drifts into the workhouse or is 
drawn into crime. On the other hand, expenditure 
incurred in the treatment, supervision, and after- 
care of physically defective children is likely to 
show a profitable return, and many of the children 
eventually become highly skilled workmen and 
valuable members of the community. 

The ordinary public elementary school is un- 
suitable for the majority of cripple-children, mainly 
for three reasons. Firstly, the children are gener- 
ally backward, and therefore in need of individual 
instruction, impossible in a large class. Secondly, 
they are, as a rule, unable in the playgrounds to 
withstand the buffeting of healthy children, and 
beyond this they are often delicate, frail, and ill- 
nourished. In other words, they require the advan- 
tages of open-air life. 

Some are so deformed as to be unable to use 
the desks and chairs of the ordinary school; to a 
few, walking is difficult; others are bedridden. 

In order to be self-supporting in after-life it is 
essential that the physically defective child should 
begin to specialise at an early stage, so as to 
acquire a degree of skill sufficient to compensate 
for the handicap which deformity imposes. 

The extent to which crippling is prevalent in 
80 



The Cripple-Child 

children of school age is somewhat difficult to 
estimate. A general survey of all abnormal 
children in attendance at school has been completed 
only in a few areas, and there is, further, a source 
of error in the fact that the names of a large number 
of cripples of school age are not on any school 
register. 

Nevertheless, it can be said that about i per 
cent, of children of school age are cripples, so that 
in England and Wales, at the present time, there 
are some 60,000 children for whom special pro- 
vision is required. Special day-schools for cripples 
can accommodate about 5,000 children, and there 
are residential schools for only about 300 cases, 
so that for the majority of cripple-children little is 
being done. This is the more to be regretted be- 
cause in the treatment of deformities modern 
methods can achieve brilliant results. 

With early recognition, prompt surgical atten- 
tion, and persistent after-care, the twisted neck, the 
curved spine, the club-foot, can be straightened and 
the child be made a normal, active individual. The 
conspicuous success of the orthopaedic hospitals 
established during the War surely points the way 
along which local authorities should proceed, and 
it is to be hoped that when these institutions have 
fulfilled their purpose of repairing the injuries of 
war, they may be used to restore health to the 
deformed victims of disease. 

G 3i 



The School Child 

The recent experience gained in the treatment 
of deformities is likely to prove extremely valuable 
in years to come, and there are already available the 
services of a considerable number of medical men 
highly skilled in this special branch of surgical 
work. 

The causes of deformity are chiefly four — tuber- 
culosis, infantile paralysis, rickets, and defects of 
development. 

Tuberculosis alone is responsible for nearly half 
of all deformities, and infantile paralysis for rather 
less than one-third. The first is the cause of 
diseases of spine, hip, and other joints. The second 
brings about wasted limbs and flail feet, indicative 
of destruction of nerve centres. 

Rickets leads to pigeon-chest, bow-legs, and 
knock-knees; while among other defects are wry- 
neck, congenital dislocation of the hip, and simple 
curvature of the spine. Wry-neck is generally 
thought to be due to injury at birth; simple spinal 
curvature is the result of muscular weakness and 
the adoption of faulty positions in standing and sit- 
ting. Less common defects are club-hand, webbed 
fingers, the congenital absence of fingers or the 
whole hand, and the deformities due to injury and 
accidents. 

The prevention of crippling must be sought in 
a reduction of the prevalence of the diseases occa- 
sioning deformities. 

82 



The Cripple-Child 

Surgical tuberculosis, which is the term 
usually applied to tuberculous infection of bones 
and joints, kills every year about 5,000 persons and 
maims at least four times that number. The origin 
of the disease is generally bovine, and the germs 
are usually taken into the human body by drinking 
unboiled tuberculous milk. 

Obviously, the first step must be the elimination 
of tuberculous cattle from the herds throughout 
the country. The second, more complete and com- 
prehensive supervision of the milk brought for sale 
into each locality. 

No person should be allowed to keep dairy cows 
unless he can produce from time to time satisfactory 
evidence of the health of the cattle and of the 
milkers. The standard of sanitation of the cow- 
sheds needs revision. To this end an adequate 
number of whole-time veterinary surgeons should 
be placed on the staff of medical officers of health. 
In every district there should be frequent systematic 
bacteriological examinations of milk, and any 
found to be infected should be carefully followed 
to the source. 

Until such time as all supplies are rendered 
free from harmful germs, milk should be boiled 
before use. 

The success which has attended the distribution 
of dried milk by various municipalities, and the 
progress shown by infants fed on this food, open 

83 



The School Child 

wide possibilities for future action. The problems 
of the transit, storage, and home contamination of 
milk would soon be solved were the use of dried 
milk to become general. From the point of view 
of public health there seems to be no solid objection 
to milk being converted into powder. Certainly, 
the fears at one time expressed that cooked milk 
would lead to the occurrence of diseases such as 
scurvy and rickets have been proved groundless. 

Surgical tuberculosis may also be caused by the 
consumption of tuberculous meat. It is essential, 
therefore, that private slaughter-houses should be 
abolished, and that all meat should pass through 
a public abattoir.* 

If surgical tuberculosis is to any appreciable 
extent of human origin, the infection arises mainly 
from persons in an advanced stage of pulmonary 
tuberculosis. For these segregation is urgently 
needed, both in the interest of the community and 
for the comfort of the sufferer. 

Even when tuberculosis of bones has begun, 
deformity can usually be prevented by appropriate 
treatment, the essentials of which are good food, 
fresh air, and absolute immobility of the affected 
part. 

The earlier the treatment, the better the prospect 

* For a fuller discussion of such questions, see "Food and 
the Public Health," by W. G. Savage, B.Sc, M.D.Lond., 
D.P.H. 1919, (English Public Health Series.) 

84 



The Cripple-Child 

of recovery. It is important, therefore, that during 
the class-to-class survey which should take place 
at least every month, the nurse should pay attention 
to signs of commencing tuberculous disease — joint- 
pains, and slight limping or stiffness of gait — and 
should refer all such cases to the Medical Officer. 

In many cases the infection takes place before 
entry to school, and it is here that maternity centres 
and nursery schools are likely to be of value in the 
detection of the beginnings of disease. 

Since deformity due to tuberculosis can largely 
be obviated by early detection and prompt and 
adequate treatment, parents should be warned to 
watch for the appearance of the danger signals — 
pains, limping^ stiffness in movement, and at once 
to seek competent surgical advice. In every area 
facilities should be available whereby the services 
of specialists can be obtained for the treatment of 
those conditions for which consultants are usually 
sought by wealthy members of society. 

Infantile paralysis is an acute infection occur- 
ring usually in those in the second and third years 
of life. In most districts a few cases appear each 
year, but from time to time epidemics break out 
in which persons of all ages are involved, with 
serious loss of life, and paralysis in many of the 
survivors. 

In a typical instance a child is noticed to be 
feverish, and a day or two later is found to be 

85 



The School Child 

unable to use one or more of its limbs. The degree 
to which permanent paralysis persists is dependent 
largely on the skill displayed in after-treatment. 
With complete rest for a prolonged period, massage 
and electrical treatment, brilliant results can often 
be obtained, and a child at the onset completely 
paralysed in every limb will, after four or five 
months, almost entirely recover and be able to walk. 

Crippling from this cause supervenes as a rule 
from failure to recognise the true nature of the 
disease and from neglect of after-treatment. The 
actual deformity is brought about by the weight of 
the body and the over-action of the muscles which 
escape paralysis. 

At present the prevention of infantile paralysis 
is virtually limited to detection and isolation of the 
sufferer, disinfection of bedding and destruction 
of vermin. Crippling can best be avoided by care- 
ful, continuous, persistent treatment. Admission 
into hospital offers by far the best chance of 
success, and in almost every case in-patient treat- 
ment should be enforced. 

Many instances of the disease, undoubtedly, are 
missed ; but home visiting, attendance at maternity 
centres and nursery schools will lead, in the future, 
to the discovery of most of the defects before entry 
into school. The regular class-to-class inspection 
of all children should reveal the extent to which the 
crippling exists in those of school age, and at every 

86 



The Cripple-Child 

school there should be a register of all physically 
and mentally abnormal children, including those 
living: in the school area but not in attendance at 
school. 

Rickets, as a cause of deformity, is responsible 
for some lo per cent, of the more serious defects; 
particularly bow-legs, knock-knees, and pigeon 
chest. The disease usually appears in the first year 
of life, and its presence is revealed by sweating 
of the head, delayed dentition, a soft flabby body 
and bony deformities. The bony deformities be- 
come more marked as the child begins to walk. 

Rickets is due to some error in feeding, and the 
most reliable evidence appears to point to a de- 
ficiency of fat in the diet or failure to absorb the 
amount which is present. It is most commonly found 
in industrial areas where overcrowding, insanita- 
tion, and ignorance of infant management exist. 

Rickets can be prevented, and, in the early 
stages, is easy to cure. The experience of medical 
officers shows that the spread of knowledge of in- 
fant feeding, following upon the establishment of 
schemes of home visiting and maternity centres, 
has brought about a reduction in the prevalence of 
this disease. 

It is now rare to discover those terrible examples 
of deformity common fifteen years ago. 

Chief among the preventive agents is the pro- 
vision of an ample supply of pure full-cream milk 

87 



The School Child 

at a reasonable cost. Municipal depots at which 
milk powder can be obtained by all, irrespective of 
income, should be opened in every town. 

Nor must it be forgotten that ill-health in the 
expectant mother may be a cause of rickets in the 
child, and that the removal of insanitation and the 
letting in of sunlight and air cannot safely be 
neglected. 

Faulty posture — One cause of deformity of the 
spine more easily preventable than any other is that 
due to faulty posture especially following upon the 
use of ill-fitting, badly-constructed desks. Even 
at the present day it is common to see children 
using school furniture several sizes too small. 

Where the desks are not adjustable, a propor- 
tion of the children are certain to be ill-fitted, 
and as a consequence there is a twisting of the 
spine, particularly damaging to a weakly, mal- 
nourished child. The separate desk with seat and 
back which can be altered to suit each occupant 
affords a remedy that no education authority can 
lightly ignore. 

How to treat crippling diseases. — Active sur- 
gical tuberculosis demands, in practically every 
case, institutional treatment. To complete im- 
mobility of the affected part, good food, and rest 
in the open air, few cases fail to respond, and even 
extensive abscess formation will subside. The 
treatment must be measured in years, not months. 

88 



The Cripple-Child 

Infantile paralysis in the early stages requires 
massage, passive movements, and rest in the open 
air. Later, operative treatment may be needed to 
correct deformities, and an apparatus may be 
necessary to prevent a recurrence of the con- 
tracture. 

In rickets suitable dieting must be provided, 
with an ample allowance of fat. As a general rule, 
children suffering from this disease should be kept 
off their feet ; by this alone bending of the legs can 
frequently be avoided. When well-marked de- 
formity of bones has occurred an operation will, as 
a rule, be needed to correct the defect. Fortunately, 
the operative treatment of deformities affords some 
of the most striking examples of the progress of 
modern surgery. The twisted limb can be straight- 
ened, the lame can be made to walk, and by the 
transplantation of muscles and nerves the paralysed 
may regain strength. 

The line of treatment to be adopted as soon as 
a cripple is discovered depends chiefly upon the 
degree of the deformity. 

In slight, non-progressive defects not needing 
surgical treatment the child may remain in attend- 
ance at an ordinary elementary school, and may 
there undergo a system of physical exercise for the 
correction of the deformity; but even these minor 
defects can more appropriately be treated at an 
open-air school. 

89 



The School Child 

In the next category are the cases requiring 
active surgical treatment, those of wry-neck, club- 
foot, tuberculosis of bones and joints, and con- 
tractures following paralysis. Children with these 
conditions should be admitted into an institution 
under the care of an orthopaedic surgeon. On dis- 
charge they may return to the ordinary school, to 
an open-air school, or to a special school for 
cripples. Whichever course be adopted, in no 
circumstances should the deformed child be left 
without after-care. 

In the first place, the defect may recur, and the 
walking apparatus, where one is used, will soon 
become too small and require attention or renewal. 
In the second place, on leaving school the cripple 
may fail to obtain employment and be driven into 
a blind-alley occupation. 

Supervision must not be allowed to cease as 
soon as suitable work is found, particularly in the 
case of girls, and the following up and home visi- 
tation should continue into adult life. 

It is a matter of satisfaction that attendance at 
a special school for cripple-children affords an 
opportunity for each child to be taught a trade ; as 
a result many become healthy workmen possessing 
technical skill in a high degree. 



90 



CHAPTER VII 
The Mentally Abnormal Child 

It is only during recent years that the State has 
begun to realise the national danger of mental ab- 
normality and the loss occasioned by inability of 
a section of the community to be self-supporting. 
There is now considerable weight of evidence to 
show that much of the crime of the country is due 
to persons suffering from varying degrees of mental 
or moral degeneracy, and that to discover, classify, 
and train the children for whom education is pos- 
sible, and to supervise and segregate the hopeless, 
is likely to be a wise and profitable expenditure of 
public money. 

In the first place, it is necessary that a survey 
should be carried out under the direction of the 
Medical Officer in each area to bring to light all 
children mentally sub-normal, including those not 
in attendance at school. Although there is no 
difficulty in forming an opinion in instances of 
serious mental defect, the detection and classifica- 
tion of the less-marked cases are beset with pitfalls. 

Broadly speaking, there are five groups of men- 
91 



The School Child 

tally abnormal children — the backward, the dull, 
the feeble-minded, the imbecile, and the idiot. 

The backward. — The backward child is one 
whose mental development has been retarded 
through lack of mental exercise. The loss of edu- 
cation may be due to irregular attendance at school, 
owing to ill-health, truancy, parental indifference 
or unsatisfactory home conditions. On the other 
hand, a child may, through physical defect such as 
deafness or blindness, be unable to follow the in- 
structions given to the class. The possibility that 
an incompetent teacher may be a cause of back- 
wardness should not be ignored. 

The first move in dealing with the problem is 
to discover those children who are too old for the 
class in which they are, and it is usual as a broad 
basis for inquiry to regard children as mentally 
abnormal who are two years or more behind the age 
of the class. The abnormal having thus been sorted 
out, a careful inquiry should be made in each case 
to discover into which group the child should be 
provisionally classified — the backward, dull, or 
feeble-minded. 

It is helpful to remember that a backward child 
is generally in the same mental stage as a bright 
child of a younger age — that is to say, the mentality 
of a backward child of lo would correspond to that 
of a normal child of 8 or 9 years of age. 

The next step must be an attempt to discover 
92 



Mental Abnormalities 

the cause of the condition. The child may have 
been late in beginning to go to school, or frequent 
changes of school may have interrupted attendance. 
Persistent ill-health, oft-recurring sore throat, 
bronchitis, enlarged glands, ringworm, sore eyes, 
and other minor ailments are other reasons for 
serious loss of education and consequent back- 
wardness. By appropriate treatment the physical 
barrier to the reception of instruction must be re- 
moved, and then, in order that the leeway may 
be made up, the child should receive individual 
tuition, an impossibility in a large class of an 
ordinary elementary school. It is generally advis- 
able, therefore, to form a special class for backward 
children. Reports from towns where special classes 
have been established show that, provided care is 
exercised in the formation and management of the 
class, very satisfactory results may be expected 
from money expended in the teaching of backward 
children. 

The teacher must be carefully chosen, and 
should be one who, besides having a natural apti- 
tude for the work, has had special instruction in the 
methods to be employed. The class should be 
small in order that there may be time for individual 
instruction. The ordinary curriculum should be 
modified to allow for manual work, physical exer- 
cises, and singing. The ages of the children 
admitted should be as little divergent as possible. 

93 



The School Child 

The younger the children are when accepted, the 
greater will be the success of the class. 

Apart from the remedying of defects, measures 
must be taken to improve the physical condition 
of the children. Open-air life, rest, shower-baths, 
and free meals should always be provided. 

In populous districts a special school for back- 
ward children can be opened, and the difficulty of 
teaching in the same class those of widely different 
ages can then be avoided. 

The experience already gained leads to the ex- 
pectation that after a year or two of attendance 
at a special class many of the children will be able 
to return to an ordinary elementary school and hold 
their place with other children. Without attention 
to health or individual instruction the outlook for 
a backward child in an ordinary elementary school 
is almost hopeless ; his presence there is a drag on 
the other members of the class, and when he leaves 
school backwardness may be a bar to remunerative 
employment. 

The dull A dull child may be regarded as 

one whose brain is structurally incomplete. The 
defect usually dates from birth or follows upon the 
occurrence of some serious illness which damages 
the brain tissues. 

Probably one of the most important ante-natal 
causes of mental defect is syphilis, an infectious 
disease which is preventable, and in the early 

94 



Mental Abnormalities 

stages not difficult to cure. The excessive uSe of 
alcohol for long periods by either parent, or the 
taking of certain drugs such as lead, may in- 
juriously affect the mental capacity of the unborn 
child. But the marriage of feeble-minded persons 
is the main source of dullness in children. 

If dullness be correctly classified as the first 
degree of mental defect due to imperfect develop- 
ment or disease, it is clear that a cure in the full 
meaning of the word cannot be expected, and that 
some amount of mental impairment will persist 
throughout life. 

It is useless to attempt to train a dull child 
in an ordinary class, and for this group of children 
special individual instruction is needed similar 
to that which should be provided for those who 
are backward. In some thinly-populated areas 
the two groups can be taught in one class ; in large 
towns they may be kept separate. An advantage of 
the combined class is that it may be used as a 
sorting ground for the observation of border-line 
instances of defect. With individual instruction 
for four or five years a dull child may leave school 
sufficiently well equipped to earn a living in com- 
petition with its normal fellows. 

The feeble-minded. — A feeble-minded child 
will never be able to earn a living in competition 
with its fellows, nor will it be able without help 
to manage its own affairs. 

95 



The School Child 

Of the extent of the defect there is as yet no 
information completely reliable, but it is probably 
an under-estimate to allow for the presence of five 
feeble-minded children in every thousand children 
in the elementary schools. A town with a htindred 
thousand inhabitants might therefore be expected 
to have to deal with about a hundred feeble-minded. 

The causes of the condition are mainly the same 
as those of the less serious structural defects which 
produce dullness; but, while there is ample room 
for further investigation and research, it is safe 
to assert that to heredity must be attributed the 
chief part in the production of the feeble mind. 

The greatest hope of success in dealing with 
this problem will lie in the segregation of those 
affected, and in steps directed towards the preven- 
tion of the marriage of the mentally unfit. But the 
education of the public in the means whereby 
venereal diseases may be prevented, and in the vital 
importance of early and thorough treatment when 
they are contracted, is likely, in the future, to 
reduce mental deficiency. 

Among the post-natal infections which are liable 
to damage the brain, infantile paralysis takes a 
prominent position ; but, unfortunately, no specific 
means of preventing this disease are yet known. 

Children who are feeble-minded will be dis- 
covered in the class-to-class survey in the schools, 
and teachers can usefully augment the register of 

96 



Mental Abnormalities 

cases by referring to the Medical Officer children 
whom they suspect to be backwark, dull, or feeble- 
minded; but many of these are not in attend- 
ance at school, nor are they on the school 
register. As soon as the medical examination 
shows that a child is feeble-minded, arrangements 
should be made for admission into a special class 
or school. 

There are, in the main, three courses which 
should be available for the training of such child- 
ren — the first at a day school, the second at a 
residential school, and the third at a colony where 
permanent supervision may be maintained. 

Day-school accommodation is required as a 
clearing centre for doubtful cases of mental defect, 
in order that it may be decided to what degree each 
child is educable, and as a training school for 
mild instances of abnormality. It is unsuitable fof 
children who need continual supervision and can- 
not travel to the centre without a guide. 

The day school should provide instruction par- 
ticularly directed to appeal to the special senses, 
the training of the speech, the handling and recog- 
nition of various objects, brick building, counting, 
and, when possible, simple reading and writing. 
After three or four years an attempt should be made 
to begin definite manual work — domestic duties, 
laundry, gardening, basket work, and any occupa- 
tion likely to be of use to the child in after-life. 

H 97 



The School Child 

The physical condition of the children should be 
improved by all available means. 

Personal cleanliness must be a first care, and 
each child should be taught to wash the face and 
hands and cleanse the teeth — a pride in personal 
appearance is one of the first lessons to be incul- 
cated. Physical exercises and organised games 
should be an integral part of the training, and 
three meals should be provided each day. 

The building need not be an expensive struc- 
ture, and should be planned on open-air lines in 
rural surroundings. With modern methods of 
transit the difficulty of access can soon be over- 
come. The advantages of ample playground space 
and opportunities for nature study outweigh the 
cost of providing means of conveyance. 

Money spent on improving the health of men- 
tally abnormal children who are educable is one 
of the best methods of insuring against failure of 
our educational system. After three months of life 
in the open air, rest, regular exercise, and suitable 
food, the change in the demeanour of some of the 
worst of these mentally defective children is re- 
markable. 

In the milder cases the attention to health alone 
appears to be almost all that is needed to bring the 
child to a normal level for receiving instruction. 

The one test whereby it can be decided whether 
a child should remain at the special day school or 

98 



Mental Abnormalities 

be transferred to a residential school or colony is 
the rate of progress. If it is clear that in spite of 
improved health there is no likelihood of benefit 
from the instruction in reading and counting or in 
manual work, the child should be certified as un- 
educable to the local authority appointed under the 
Mental Deficiency Act. 

A residential school will be needed for children 
living under unsuitable home conditions, for those 
coming from thinly populated areas where special 
day-school accommodation is impossible, and for 
marked examples of educable defect. The building 
should be in the country and of the open-air type. 
Ample grounds are essential for games, gardening, 
poultry-keeping, and other out-of-door occupations. 
It is advisable to have several separate pavilions to 
allow for some distinction to be drawn between the 
various degrees of defect, and for administrative 
reasons. 

A permanent home or colony should be estab- 
lished for that residue of mentally abnormal 
children, including the imbecile and the idiot, 
which is uneducable or requires continual care. 
Many of the hopeless defectives are now to be 
found in Poor Law infirmaries, and some are kept 
almost concealed at home. Most of these children 
require constant supervision in comfortable cleanly 
surroundings such as only institutional life can 
provide. For economy in construction and general 

99 



The School Child 

working the colonies should be adapted to accom- 
modate a large number o'f inmates. Although the 
imbecile and the idiot should remain for life, 
constant medical inspection should allow for the 
possibility of improvement and discharge. 

For mentally defective children responsive to in- 
struction, but too low in grade to be allowed out in 
the world unassisted, colony life is the only safe- 
guard against poverty, misery and crime. 

The epileptic. — The case of the epileptic must 
now be considered. He suffers from a malady 
which, in the slight and not progressive manifes- 
tations, may exert no noticeable influence on in- 
tellect. Except for the occurrence in school of 
occasional fits, no hindrance to education will be 
likely to arise. 

Unfortunately, epilepsy tends to cause a de- 
terioration in the mental condition of the child. The 
earlier the onset the more serious the outlook — the 
rriore frequent the fits the more marked the mental 
damage. The disease is not common. Various in- 
vestigators have arrived at different conclusions with 
regard to the prevalence of epilepsy. Probably one 
child in about every five hundred suffers from the 
defect. The cause of epilepsy is unknown. Here- 
dity seems often to be the only explanation, but in 
many instances no family history of the disease can 
be obtained. Injury at birth or damage to the 
brain by an infectious disease contracted in early 

lOO 



Mental Abnormalities 

childhood is occasionally the starting-point of the 
epileptic fits. 

The first essential in the management of an 
epileptic child consists in healthy living — regular 
hours of sleep, rest during the day, ample, nourish- 
ing, easily digested food, physical exercise and 
open-air life. The next requirement is regular 
medical supervision to discover the factors which 
bring about the onset of the fits, to take such steps 
as may be practicable to reduce the frequency of 
the attacks, and to improve the general condition 
of the child. 

The type and amount of instruction which an 
epileptic can receive depend mainly on the degree 
of mental impairment. In mild cases attendance at 
an ordinary elementary school may be advised. 

Indications that the disease is leading to mental 
enfeeblement point to the need for institutional 
treatment, and it is not far wide of the mark to 
assert that the vast majority of epileptics would be 
under better conditions in residential schools than 
at home. The orderly routine of institutional life, 
the constant medical care, with training graduated to 
the capabilities and requirements of each child, pro- 
vide for epileptics the most favourable conditions 
for acquiring permanent bodily and mental health. 

A colony for epileptics should be under the 
direction of a resident medical superintendent. The 
acreage and number of patients admitted should be 

lOI 



The School Child 

sufficiently large to allow of all the advantages of 
communal life, with dairy work, poultry-keeping, 
gardening, laundry, and workshops for various 
trades. Arrangements should always be made for 
the services of a dentist, an ophthalmic surgeon, 
and other specialists. As branches of the institution 
it will be necessary to set apart special pavilions for 
the reception of low-grade, feeble-minded epileptic 
children for whom training is useless. That the 
results obtained may be as permanent as possible 
it is advisable that suitable cases should remain in 
the colony for long periods. The automatic dis- 
charge from school of the children at the age of 
i6 is often fraught with grave consequences. 

After-Care. — Much of the care expended in 
the training of children who are mentally abnormal 
will be in the end unavailing unless there are in 
every area adequate arrangements for the persistent 
following up of each child after it leaves the special 
class or institution. Some degree of after-care is 
needed by almost every normal child — assistance 
in the choice of suitable employment, facilities for 
recreation, for study, and, above all, opportunities 
for free dental and medical treatment. Much more 
is after-care necessary for those who are backward, 
dull or feeble-minded. Not only is it essential that 
such work shall be found as the child is able to do, 
but the conditions of labour must be continually 
kept under observation. Every endeavour must be 

I02 



Mental Abnormalities 

made to prevent unemployment; to this end the 
establishment of municipal workshops has been 
suggested, and from several points of view there 
is much to be said for the idea. The experience of 
various after-care agencies seems to show that with- 
out supervision many of the feeble-minded children 
fail to hold their own, and after a few years' com- 
petition with normal individuals drift into the ranks 
of the unemployed. 

After-care should also extend to the provision of 
holiday camps, thrift clubs and other agencies for 
promoting the physical and mental welfare of school 
children in general. In organising a system of after- 
care, it is well to remember that during some nine 
years of school life the supervision of the children 
is carried out by trained nurses under the direction 
of the Medical Officer of the area. The satisfactory 
results which have been obtained through the 
efforts of the School Medical Service make it seem 
worthy of consideration whether public funds 
should not be made available so that following up 
and after-car^ could be maintained beyond school 
age by those at whose hands the child has received 
early training and attention. Continuity in methods 
of education and treatment would then be possible, 
and there would be the additional advantage that 
the welfare of each child would become a matter for 
the personal guardianship of the few, whereas now 
it is mainly of academic interest to many. 

103 



CHAPTER VIII 
School Buildings 

Far too little importance has been attributed to the 
influence which school buildings can bring to bear 
on the health and education of children. Too 
frequently it appears to be forgotten that for some 
nine years the school provides the principal en- 
vironment of the child, and should therefore, in 
design, sanitation and surroundings, set an example 
for the home, the office, and the workshop. That a 
dark, ill-ventilated class-room will injuriously affect 
the physical condition of the occupants the reports 
of medical officers conclusively show, but there is 
still hardly any appreciation of the opportunities 
for teaching personal cleanliness and domestic 
hygiene afforded by a modern, well-constructed 
school. 

The value of the open window, the use of the 
fireplace as a means of ventilation, the advantages 
of sunlight, the dangers of dust and dirt are sub- 
jects which can easily be illustrated by reference to 
structures in the school. 

The inculcation of habits of cleanliness loses 
104 



School Buildings 

much of its force when there are neither hand 
basins, bowls, nor soap on the premises, and the 
only cloak-room is a passage leading into school. 

Lofty, light, airy schools will breed a spirit of 
discontent with the insanitary houses from which 
many of the children come, and will eventually lead 
to an improvement in the homes and workplaces 
throughout the country. 

Unhappily, there are yet in use as schools a 
large number of buildings which structurally and 
through gross errors in sanitation are totally un- 
suitable for the purpose. 

While the impossibility of at once sweeping 
away these centres of ill-health is recognised, it is 
surely not too much to hope that education authori- 
ties generally will speed on the provision of build- 
ings worthy to be object lessons in the fundamental 
principles of sanitation. 

Until recent years it was considered essential 
that a school should be as near as practicable to the 
homes of the children, and to this end, in urban 
districts, it is common to find school buildings 
situated adjacent to works or abutting on to a main 
thoroughfare. But now improvement in means of 
transit and the opening up of rural areas adjacent 
to towns render possible the utilisation of suitable 
sites in the country, free from undesidable sur- 
roundings. The land on which a new school is to 
be erected should be sufficiently extensive to allow 

105 



The School Child 

for Open-air education and for organised games. 
At times these requiremxents may be met by the use 
of a pubUc park near by. 

The site should be exposed to the sun and 
screened as far as possible from the prevailing 
winds; it should be free from dust, smoke and 
noise, so that the windows of the class-room can be 
open throughout the year. 

The minimum area of the site should be based 
on the standard of an acre for every 200 children, 
with additional land for special purposes, such as 
school gardens, cookery centre, or caretaker's 
house. Unless a playing-field is provided for 
organised games, the area of the playground should 
be 8,000 square feet for 200 older children. There 
should be separate playgrounds for boys and girls, 
and for infants, but every endeavour should be 
made to obtain a field for cricket, football and other 
games. When a playing-field is acquired, the 
playground need only be sufficient for physical 
exercises. 

While fully admitting the desirability of large 
schools with separate departments, each depart- 
ment with a head teacher, it must be urged that 
a department should not contain rhore than 400 
children, so that the whole school would provide 
accommodation for 1,200 children. In some in- 
stances it may be necessary to admit as many as 
1,800 children; it is then advisable to build two 

106 



School Buildings 

junior departments, and a senior department, each 
for boys and girls, retaining the juniors until they 
reach the age of nine or thereabouts. 

Unless the land is very costly, the school should 
be of one storey only, and so arranged that each 
class-room has windows on opposite sides, giving 
direct access to the open air. Until recently it was 
thought that the windows on one side of a class- 
room might open into a corridor or hall. This 
method of ventilation now stands, condemned, and 
no education authority should, in any circum- 
stances, countenance the erection of a school which 
does not allow each class-room to obtain fresh air 
on opposite sides. 

Each department should be self-contained and 
possess separate entrance, class-rooms, cloak-rooms, 
teachers' rooms, store-rooms, lavatories and closets. 
A common hall may be provided for the elder boys 
and girls, but, as a rule, the infants should have 
a separate hall or playroom. 

The hall must be well lighted, warmed and ven- 
tilated, and so placed that noise in it will not dis- 
turb the work carried on in the class-rooms; for 
these and other reasons it is often convenient to 
build the hall detached from the school. The floor 
space of the hall should be calculated at 3^ square 
feet at least per child, with a maximum of 1,500 
square feet. 

For infants a separate small hall or playroom is 
107 



The School Child 

essential in order that the children can march and 
play indoors ; this room must also be detached from 
the class-rooms. 

The class-room should generally not accommo- 
date more than thirty children, although forty, 
under certain conditions, may at times be allowed. 
Not only must each class-room be ventilated from 
the open air by windows on opposite sides, but one 
side should so be made that it can be thrown com- 
pletely open, and so arranged that it can be cleared 
without disturbing any other class. Each room 
should have a fireplace at the teacher's end of the 
room in the corner remote from the door. The 
floor space should not be less than lo square feet 
per head; in the case of infants 9 square feet may 
be allowed ; but a play-room should provide at least 
12 square feet per child. 

In height the class-room should measure at least 
12 feet, unless there are windows on opposite sides, 
when the height of the room may be slightly re- 
duced, and the tops of the windows should reach 
almost to the ceiling. The windows should be of 
clear glass, and should be so constructed that they 
can be completely opened. French casement win- 
dows can be used for one side of the room. The 
minimum window space should be one-quarter of 
the floor area, but one-third is a more satisfactory 
proportion. In no circumstances should a window 
face the scholars or the teacher. As far as possible 

108 



School Buildings 

the windows on one side of the room should 
look towards the south-east or south. Ventila- 
tion should be carried out by windows and the 
fireplace. Wall gratings and other air inlets or 
outlets of various types are unnecessary, and should 
be avoided. 

A teacher can do much to instil into the minds 
of children an appreciation of simple lessons in 
hygiene by timely reference to the proper use of 
the window and the fire. 

One of the most important details in ventilation 
is to ensure that the cold air sinking to the floor 
does not chill the feet of the scholars. The danger 
may be overcome by converting the lower part of 
the windows into a hopper with closed sides, 
thereby directing upwards the incoming current of 
air. The radiators placed under the windows bring 
about the same result. Schemes of artificial venti- 
lation providing for the supply of hot air to the 
class-rooms should be rejected. Air which has been 
tampered with loses its freshness, and devitalised 
air is generally undesirable. 

The heating of a school is best effected by a low- 
pressure hot-water system to be used in conjunc- 
tion with open fires ; the radiators should be placed 
under the windows, and about 30 feet of heating 
surface allowed for each 1,000 cubic feet of air space 
in the room. Slow combustion stoves and gas 
radiators should not be used in schools. These 

109 



The School Child 

methods of heating are dangerous ; they pollute the 
atmosphere and are otherwise unsatisfactory. 

The water supply must be adequate and pure. 
In most instances a public supply will be available, 
and will be laid on to closets, lavatories and special 
centres. For drinking purposes the use of the 
common cup should no longer be permitted ; it is 
undoubtedly responsible for the spread of many 
diseases, and has nothing to commend its retention 
in schools or elsewhere. Each department should 
be provided with one or more fountains with an 
upward jet, so that a child can drink by holding 
the mouth above the aperture from which the water 
is forced. No part of the fountain can come into 
contact with the lips of the child. 

In country districts it may occasionally be 
necessary to pump water from a properly con- 
structed well into a storage cistern from which 
drinking water can be supplied, but any water 
needed for the flushing cisterns of closets or urinals 
must be obtained from separate storage. Each de- 
partment must be provided with sufficient facilities 
for washing, and not less than four basins for every 
fifty children will be required if the children are to 
be instructed in personal cleanliness. The basins 
should not be placed in a passage or cloak-room, 
but be fitted in a room set apart for the purpose. 
The entrance and exit should be separate. The 
walls in front of the basin should be tiled and the 

no 



School Buildings 

floor should be impervious, and channelled to a 
gully outside the building. The room should be 
thoroughly ventilated, well-lighted and discon- 
nected from the class-rooms. Soap should be avail- 
able, but the common towel ought not to be allowed. 
Probably the only satisfactory alternative is to 
insist on each child bringing to school and using 
daily a towel, brush and comb. 

A cloak-room of ample dimensions is essential 
for the health and comfort of children. It must be 
well ventilated, and specially constructed to allow 
of the drying of wet clothing. The room should 
be near the entrance in each department, 
and be sufficiently commodious to permit 12 
inches of hanging space for the clothing of each 
child. 

It is advisable to hang in one tier only. In 
order to meet the need for rapid drying, the frames 
on which the clothing is suspended may be made to 
be drawn up into the enclosed freely ventilated and 
heated portion of the room. The floor must be 
impervious, and constructed to drain into a gully 
outside the building. The walls should be tiled, 
and there should be a gangway of at least 4 feet 
between the rows of pegs. Wire cages for footgear 
are desirable, and in schools drawing children from 
long distances it is well to provide a small room 
in which the clothing may be changed. 

Each department must have a complete equip- 
III 



The School Child 

ment of sanitary conveniences for the children, in 
a building entirely disconnected from the school. 
The closets and the approaches to them must be 
separate for boys and girls. Care should be taken 
so to arrange the building that there is privacy of 
access, and that windows of the school or of neigh- 
bouring property do not overlook the closets or 
urinals. Each closet should be ventilated, lighted, 
and have a door 3 inches short at the bottom and 
6 inches short at the top. In each compartment 
there should be a single pedestal hand-flushed 
closet basin, with a separate flushing cistern. It is 
unreasonable to expect children to use properly the 
closets in their homes unless they are taught as a 
routine to flush the closets at the school. Any 
automatic system of flushing should be rejected on 
educational grounds. 

It is usual to recommend one closet for every 
fifteen girls, and one for every twenty-five boys. 
In infant departments each seat must be of suitable 
size and height for young children, but it is totally 
erroneous to consider that children 4 or 5 years 
of age are not strong enough to pull the chain of a 
flushing apparatus. 

For the boys, urinals should be provided in the 
proportion of 10 feet of urinal to every hundred 
children, and it is necessary to arrange for an auto- 
matic flushing system. 

It is advisable to divide a urinal into stalls, but 

113 



School Buildings 

in any case the urinal should be partitioned off from 
the closets. 

At the present time there are, even in urban 
districts, many schools where the children are com- 
pelled to use a pail closet or open pit. These dis- 
gusting contrivances should no longer be permitted 
to endanger the health of the scholars. 

In some country areas it may be impossible to 
secure a water-carriage system, but inasmuch as 
drains have to be provided for rain and slop water, 
the instances in which earth closets have to be fitted 
should be extremely rare. 

Not only on grounds of health should every en- 
deavour be made to provide separate hand-flushed 
water-closets. Any scheme of education which does 
not train a child in personal cleanliness and the 
simple rules of a healthy life, or fails to hold forth 
the school as an ideal, is based on a wrong founda- 
tion. School buildings and equipment should be 
such that it is the ambition of each child to own a 
house possessing the improvements of a modern 
school. 

Every child must have a suitable seat in the 
class-room. For infants small tables with arm- 
chairs should be supplied. In no circumstances can 
forms without backs be considered satisfactory. 
For older children single or dual desks are ad- 
visable, but whatever method of seating is pro- 
vided it is essential that the seat should He adjust- 

I 113 



The School Child 

able to the size of the occupant. The feet of the 
child should rest comfortably on the floor, the 
thigh should be horizontal and the leg vertical. 
The back of the seat should fit to the curve of the 
back of the child, and there should be support as 
high as the shoulder blades. The writing surface 
should be of such a height that the child can 
sit comfortably upright while writing, and 
the edge of the surface should just overlap 
the edge of the seat. Desks can now be obtained 
with the seat, back, and writing surface easily 
adjustable. 

Permanent injury to the spine may be brought 
about by the use of ill-fitting desks or forms, and 
damage to the eyesight may follow upon cramped 
positions in reading and writing. 

The slate and sponge should be permanently 
abolished from the school, and a pencil or pen in 
common should no longer be permitted. Every 
child should have a small labelled box in which to 
keep writing and drawing materials and other per- 
sonal objects. In infant departments, particularly, 
infectious diseases have unquestionably been 
spread by the common use of various articles. 
Every effort should therefore be made to reduce as 
far as possible the risk from contamination of pen- 
cils, toys, towels, modelling clay, sand heaps, and 
drinking utensils. 

In times of epidemics, cleansing, disinfection, 
114 



School Buildings 

or the total prohibition of the common use of these 
articles should be enforced. 

Blackboards should have a dead black surface, 
and be painted at regular intervals so that there 
may be the maximum contrast between the white 
chalk and the black board. A greasy surface is 
difficult to write upon and a source of strain to the 
eyes of the scholars. The illumination of the sur- 
face should be considerably in excess of that of the 
rest of the room, and in order that this may be 
possible without glare, it is necessary to shade the 
blackboard lights so that the direct rays of lamps 
do not fall on the eyes of the children. 

The subject of the artificial lighting of schools 
is intimately related to the physical welfare of the 
children. In the first place, there is an appreciable 
risk that ill-lighted rooms may injure the sight, 
and particularly is it dangerous to attempt to do 
fine needlework in artificial light. Secondly, it is 
important that shadows should not be thrown on 
the reading and writing surface ; and thirdly, every 
reasonable precaution should be taken to prevent 
the occurrence of glare. In other words, a careful 
system of shading of the lights must be arranged 
so that the direct rays do not cause a temporary 
blurring of vision. Shining polished surfaces of 
walls, desks, or paper are very liable to increase the 
glare, and should, as a consequence, be avoided. 
Nor must it be forgotten that gaslights consider- 

"5 



The School Child 

ably pollute the atmosphere ; rooms in which gas is 
used should therefore be freely ventilated. A soft, 
steady light, well shaded and diffused throughout 
the room from a dull white surface, should be the 
aim of those responsible for school construction. 

In school construction far too little attention has 
been paid to the provision of suitable accommoda- 
tion for the teachers, and it is common to find that 
buildings have been erected without a room set 
apart for the teaching staff. In a large modern 
school there should be near the entrance, for each 
teacher, a room in which parents and scholars can 
be interviewed, and generally work undertaken 
which cannot be transacted in a class-room. Near 
by a lavatory and closet should be provided. 

Separate common rooms for men and women 
teachers will be necessary, and facilities should be 
available for simple cooking for a midday meal. 
Among the furniture of the room should be a cup- 
board and comfortable easy chairs. The common 
rooms should be situated in such a position that 
supervision can be maintained over the play- 
grounds. 

Cloak-rooms, lavatories and closets must be pro- 
vided for the staff, and for women these must be in 
the school. The cloak-room should contain lockers, 
seats and boot racks, and means whereby the dry- 
ing of wet clothing and footwear can be carried 
out. The lavatories should also contain lockers, so 

ii6 



School Buildings 

that each teacher can keep on school premises a 
hair-brush, towel and other personal articles. The 
closets should not open out of the teacher's room, 
nor should the access to them be under the obser- 
vation of the children. 

To meet the requirements of teachers living at a 
distance from the school it may be thought advis- 
able to use a room for the storage of bicycles. A 
lock-up building in the playground is generally 
more convenient than a room in the school. 



^7 



CHAPTER IX 
The School Annexe 

One of the most hopeful signs of the awakening 
of the nation to the importance of securing a healthy- 
childhood is seen in the gradual elimination of the 
small insanitary school and its replacement by 
large, light, airy buildings — object lessons, it may 
be repeated, in the value of cleanliness and 
sunshine. The modern public elementary school 
should be for each child something more than walls 
within which it is forced to spend nine of the most 
impressionable years of life. It is within the power 
of local authorities to provide schools which shall 
be completely equipped, self-contained units for 
each locality, offering to the children of the people 
such facilities for health and education that life in 
the public elementary school will be a pleasant 
memory in after years. Each new school should be 
sufficiently large to allow for the following annexes, 
viz. a canteen, a gymnasium, a treatment centre, 
baths, playground, and playing-fields. 

The canteen. — The school canteen is rightly 
regarded as an essential element in the constitution 

ii8 



The School Annexe 

of every school, and it is difficult to over-estimate 
the value of systematic and adequate arrangements 
for the feeding of children. To take the lowest 
ground, it is a waste of money to attempt to educate 
children so ill-nourished that they are unable to 
profit by the instruction given, but, far beyond this 
aspect, health and comfort, as well as economy, 
point to the need for the provision of meals for all 
school children. 

It is the experience of every Medical Officer 
that, in industrial areas particularly, it is a common 
sight to see children hurrying to school with their 
breakfast in their hand. Often, too, the distance 
to be traversed allows only a few minutes in the 
house for the midday meal. With a canteen on the 
school premises the food can be taken at leisure and 
in comfort, and there is ample time for washing 
before dinner and for a period of rest after. 

Nor must the educational side of school feeding 
be valued lightly. Personal cleanliness, the orderly 
use of the knife, fork, and spoon, good manners 
during the meal, and an appreciation of table deco- 
ration can all be gained in the well-managed school 
canteen. Certainly, the catering can be carried out 
more economically in school than in the average 
home, and more appetising and more nutritious 
meals can be put before the children than are 
possible under the conditions of a working-class 
household. 

119 



The School Child 

The canteen should be on the school premises, 
and the kitchen and scullery be fully equipped with 
modern cooking utensils. A steriliser should always 
be provided so that every article in common use 
can be steamed after being washed. This pre- 
caution is essential if the spread of infectious 
diseases is to be avoided. The dining hall should 
be light, airy, and roomy enough to permit of the 
free movement of those waiting on the children. 
The supervision of the centre and the entire man- 
agement should be in the hands of the head teacher 
of the school, who should have a competent cook 
and domestic staff. All purchases should be made 
through a distributing depot, and there should be 
little storage of perishable articles at the canteen. 
In some districts where the feeding centres are 
small the preparation and cooking is carried out at 
a central kitchen and the food is conveyed to each 
canteen in insulated containers. With a large 
school the most satisfactory method is the self- 
contained canteen, under the control of the head 
of the school. 

The method of selecting the children to be fed 
varies in different localities, and it is unfortunate 
that, as a rule, the poverty test should be employed. 
On this test alone many who greatly need food are 
ignored. Beyond all question, the method most 
likely to result in a general improvement in the 
physical condition of the children is that which 



The School Annexe 

allows for the selection of suitable cases by a trained 
nurse under the direction of the medical officer. 
By the regular daily survey of all children in school 
by a nurse acquainted with the conditions obtain- 
ing in the homes, few cases requiring the provision 
of meals should be overlooked. Medical officers 
generally should keep closely in touch with the 
work of the school canteen and utilise the oppor- 
tunities for research work afforded by the children 
in attendance at the feeding centres. Much more 
might have been done in the past to investigate the 
scientific aspect of this and other problems had the 
School Medical Service been adequately staffed. 

Most useful pioneer work has been done by 
many authorities during the last decade in estab- 
lishing and maintaining feeding centres, and the 
remarkable physical and mental improvement 
shown by the children and their increased capacity 
to benefit by the instruction provided have won a 
permanent place for the school canteen. 

The time is surely ripe to consider whether a 
system of school meals should not be adopted 
throughout the country. In every new school, at 
least, a suitable annexe should be provided for the 
preparation and serving of food. In rural areas it 
is now quite common for children to bring a mid- 
day meal to school. Even among the small schools 
there are few in which some arrangements for 
simple cooking could not be made, and in country 

121 



The School Child 

districts adjacent to towns more use could be made 
of the large schools erected by the urban 
authorities. 

The gymnasium. — A universal system of 
physical training beginning in the infant depart- 
ments of the public elementary schools and adapted 
to meet the requirements of the growing child must 
form the basis of any sound scheme for safeguard- 
ing the health of the nation. The training gene- 
rally advocated for use in schools is that embodying 
free standing Swedish exercises, together with 
certain gymnastic games and simple dance steps, 
while in the infant departments, particularly, 
breathing exercises should be taught. 

First, it is essential that the teachers themselves 
should have undergone a course of instruction not 
only in the performance of the exercises but in the 
methods of teaching to be employed. A clever 
performer is by no means always a capable in- 
structor. Secondly, little benefit is likely to accrue 
from physical exercises unless the children enter 
into the spirit of the movements, and are permitted 
to give vent to the feeling of exhilaration which 
should arise from the drill. Thirdly, no oppor- 
tunity should be lost of taking the training in the 
open air. 

Although a gymnasium and its equipment are 
not absolutely indispensable for physical training 
of the Swedish type, yet it is undeniable that appa- 

122 



The School Annexe 

ratus exercises greatly increase the enjoyment and 
add to the success of the scheme. For these and 
many other reasons every modern school should 
have a gymnasium. 

While Swedish exercises should, as a rule, be 
carried out in the open air, during inclement 
weather a modified course can occasionally be given 
in a class-room. 

The importance of teaching indoor and play- 
ground games should not be overlooked. Develop- 
ment of the powers of observation, of the muscles, 
heart and lungs is stimulated by the physical exer- 
cise and love of play engendered by circle games 
and those which permit many children to take part 
at the same time. 

Simple dance steps appropriate for infant de- 
partments, and national dances — jigs and reels — 
are extremely useful forms of physical training, 
promoting orderly movement, self-control and 
graceful carriage. 

Probably one of the most useful exercises for the 
infant departments is that known as pocket-hand- 
kerchief drill. At a given word each child produces 
a handkerchief, and then in a regular sequence of 
movements the class go through the process of 
breathing in, blowing the nose, wiping the nose, 
and putting the handkerchief in the pocket. The 
urgent need of this procedure, and of breathing 
exercises, is general, for on entering school few 

123 



ThelSchool Child 

infants possess a pocket-handkerchief, and hardly 
one knows how to use it. 

The playground. — Too little attention has in 
the past been given to the provision of suitable 
playground accommodation. Local authorities 
have been hampered by the prohibitive cost of the 
land adjacent to the schools, and there has been 
some confusion with regard to the purpose for 
which the playgrounds were intended. On the 
other hand, in some districts an attempt was made 
to use the playground as a playing-field, and in 
others the space provided was so inadequate as to 
furnish little more than an airing court. 

At the present time sufficient land should be 
obtained to allow for outdoor physical exercises, 
playground games, and open-air classes, but no 
attempt should be made to provide for organisel 
games such as football or cricket on school premises. 

The surface of the playground should be level, 
smooth, but not slippery, and carefully channelled 
so that after rain it soon becomes dry. It is im- 
portant that no part of the surface should be left 
unpaved; flower borders and allotments are more 
likely to succeed when cultivated some distance 
from the school, and uncovered areas of soil are 
soon trodden into quagmire in wet weather. 

There should be separate playgrounds for boys 
and girls, but infants can share the girls' play- 
ground if the area is sufficient. 

124 



The School Annexe 

It has been recommended by a Departmental 
Committee that where other provision is made for 
games, every undivided playground for 200 chil- 
dren should provide 20 square feet for each older 
child and 16 square feet for each infant. 

Where there is no other provision for games the 
amount of space allowed for older children should 
be increased to 30 square feet. 

A roof playground is a possibility in areas where 
the site is very expensive. 

Playing-fields. — Only during very recent 
years has serious consideration begun to be given 
to the advisability of providing playing-fields in 
connection with public elementary schools. 
Children living in industrial districts are generally 
left to accommodate their games to the topography 
of an alley or a waste heap. A wall is the wicket 
and two coats form the goal. The time has come 
to give the children of toWn people a chance to gain 
that initiative, self-reliance and robust vigour of 
mind and body which for centuries was so well 
acquired on the village green and on the playing- 
fields of public schools. 

The field can be in the outskirts of the town 
and reasonably easy of access, and it can be used 
by several schools provided that each has a reason- 
able time every week for play and practice. The 
half-day match, when more than three-quarters of 
the children act as spectators, is a totally insufficient 

125 



The School Child 

use of the opportunities for exercise afforded by a 
playing-field. Organised games should be directed 
by a teacher, who will be responsible for the man- 
agement of the ground and the conduct of the 
children. Cricket, football, hockey and tennis 
should be taught, and running and jumping and 
other forms of school sports taken up. The avidity 
with which children turn to active exercise, par- 
ticularly of a competitive nature, makes it desirable 
that a close watch should be maintained to detect 
signs of heartstrain, especially in those entering 
for school sports. A medical grading might be 
carried out, so that to physically delicate children 
special exercises could be given to remedy their 
defects. 

Swimming. — Among other physical exercises, 
swimming should be generally taught to children 
attending the public elementary schools. It is in 
all respects likely to endow a child with self- 
reliance and fearlessness, and may at any time be 
a means of saving life. Suitable arrangements 
should be made so that each child must have a 
shower bath and a cleansing of the skin, particu- 
larly of the feet, before entering the water, and a 
medical survey should always be carried out to 
exclude from the plunge bath children who are 
verminous, have discharging ears, or are other- 
wise likely to be a source of infection. In most 
localities there are insufficient facilities for swim- 

126 



The School Annexe 

ming, and as a result far too many children are 
allowed to be together in the bath— an unwhole- 
some state of things, which is also prohibitive of 
individual instruction. 

It should be an aim of the teachers of physical 
exercise to promote competitions between the 
various schools in each area, and local authorities 
by the gift of trophies can do much to encourage 
a spirit of rivalry in all branches of school work. 

School baths. — Already several towns, in 
erecting new schools, have made provision for 
school baths, and the plans for every modern 
school should allow for bathing on the school pre- 
mises. To economise in floor space and water, it 
is usual for spray and shower baths only to be in- 
stalled, but experience has shown the need of 
slipper baths as well. 

Baths must be supplied with both hot and cold 
water, and should be sufficient to permit of twenty 
children bathing at one time. Dressing boxes will 
be needed, and an attendant must always be present 
to supervise and assist. By taking the children in 
relays it is quite possible to deal with a class of 
forty children in an hour, and to bath each child 
once a week. To the advantages to be gained from 
regular cleansing it is hardly necessary to refer. 
The general health of the children improves; they 
become more alert and better able to benefit by the 
instruction given. No less important is the fact 

127 



The School Child 

that they are trained in personal cleanliness, and 
soon begin to appreciate the comfort and sense of 
well-being following upon the taking of a bath. 

In connection with schools already built it may 
be possible to provide baths in a basement or out- 
building, or a new school can be used as a centre 
for children attending other schools in the neigh- 
bourhood. In instituting the use of school baths, 
it is important that the children should be made to 
feel that bathing is a routine, and not a punishment 
for uncleanliness. Further, the baths should be 
considered a preliminary to swimming exercises, 
and not a substitute for them. 

Play centres. — It cannot be doubted that school 
buildings might be utilised to a greater extent in 
the social life of the children. As play centres in 
the evening and during the holidays, the schools 
might come to be looked upon as a club to which 
the children could resort for recreation and amuse- 
ment. For a playground outside school hours, a 
town child now has hardly any choice but the 
street. 

Treatment centres. — A treatment centre 
must be regarded as an essential annexe of every 
large modern school, but the number of rooms re- 
quired will depend to some extent on the amount 
of decentralisation considered advisable in any 
area. It is now usual to find established in each 
urban area que or more centrally situated clinics at 

128 



The School Annexe 

which minor and major ailments and defects are 
treated. While it is clear that the removal of tonsils 
and adenoids and the X-ray treatment of ringworm 
can for many reasons best be carried out at a fully 
equipped central building, there is evidence point- 
ing to the desirability of dealing on school pre- 
mises with minor ailments and some other con- 
ditions. When children are sent from school for 
treatment at a clinic there almost invariably follows 
a considerable loss df time and education, and some 
irregularity fn attendance at the centre. These dis- 
advantages are the more marked as the distance to 
be traversed increases. 

Every School Medical Officer should have a staff 
sufficient to permit of the daily visiting of each 
school by a trained nurse, who, during her survey 
of each class, can refer for attention minor ailments 
and trivial defects. The treatment can be given in 
a room provided for the purpose at the school. The 
room should have a supply of hot and cold water 
and be fitted with a sink. 

It is essential that lighting and ventilation 
should be adequate, and for this reason, at least, 
the room should not be in the basement. To meet 
the need of accommodation for medical inspection 
and the testing of vision, the length of the room 
must be at least 20 feet, but it is generally more 
satisfactory to set apart a second room for medical 
examinations. 

J 129 



The School Child 

Doubtless the time is not far distant when every 
large modern school will have rooms for medical 
inspection and for the treatment of minor ailments, 
dental defects, and defective vision. Until such 
provision is made general, the many disadvantages 
arising from travelling consequent on treatment off 
the school premises will continue to be an obstacle 
to the progress of school medical work. 

A central clinic for two purposes will, as a rule, 
be found necessary. Firstly, for the inspection of 
children requiring a more complete examination 
than is possible at school, and of those concerning 
whose condition the nurses and teachers may desire 
information. Secondly, for the treatment of ail- 
ments and defects. The accommodation to be pro- 
vided will depend on the number of children likely 
to be in attendance. A large, light, airy waiting- 
room must be the first consideration, and here the 
children should be under supervision, even though 
there be only a short interval to wait for treatment. 
Leading off the waiting-room should be separate 
rooms for the treatment of minor ailments, for 
operations on the nose, the throat, dental work, 
the correction of defective vision, and the applica- 
tion of X-rays. A consulting-room must also be 
provided, and in some instances a dispensary. In 
all, about twelve rooms will be needed in a complete 
scheme for the treatment of the more common de- 
fects in school children. 

130 




§ 5^ 



The School Annexe 

An exit separate from the entrance is an advan- 
tage to a treatment centre, and it is generally 
advisable to avoid the use of stairs as much as 
possible. The need of extensions must be borne 
in mind, for it is rare for a centre not to require 
enlargement. 

For dental work a well-lighted operating-room 
is essential, and, adjoining, a recovery-room should 
be provided. For the removal of tonsils and ade- 
noids and other operations necessitating a general 
anaesthetic, three rooms should be set aside — for 
undressing, operating, and recovery. In an emer- 
gency it may occasionally be found necessary to 
detain a child overnight, and to meet this, a room 
fitted as a single-bedded ward is always useful. 

In almost every instance central heating is the 
most economical method, and in some districts it 
has been found advantageous to utilise one or more 
rooms at the clinic as a cleansing centre. If this 
course be adopted, a steriliser for clothing must be 
added, as well as a bath-room. These will allow of 
the treatment of itch being undertaken with some 
prospect of success. 

The staffing of the clinic should be in the hands 
of the Medical Officer, and by far the most satis- 
factory system is that by which arrangements are 
made for treatment to be carried out by men who 
are specialists in the various branches of the work 
^na£sthetists, ophthalmic surgeons, and other 

131 



The School Child 

experts. To ensure this, one of two courses may- 
be followed : a whole-time specialist can be ap- 
pointed if the school population is sufficiently large, 
or the part-time services of consultants may be re- 
tained; but in no circumstances should the treat- 
ment be left to a rota of general practitioners. An 
expert in several branches of medicine or surgery- 
exists only in his own imagination. 

Dental treatment should be carried out by 
whole-time school dentists in the proportion of one 
dental surgeon to about 2,500 children to be treated 
annually. In no district as yet is the dental treat- 
ment adequate when measured by this scale. 

The nursing staff should be fully trained, and 
under the supervision of a matron or sister-in- 
charge. The size of the staff will be determined by* 
the amount of work performed at the centre, and in 
particular by the number of children with minor 
ailments. One nurse can thoroughly treat only 
about twenty children in an hour. Each dental 
surgeon needs the whole-time services of a nurse, 
and at least three nurses are necessary at throat 
operations. The nurses at the treatment centre may 
be regarded as a reserve from which to draw as 
necessity arises. In some localities it has been 
found an advantage to use school clinic nurses for 
the home nursing of cases of ophthalmia, pneu- 
monia, tuberculosis and other serious illnesses, and 
there is much to commend this co-ordination in 

133 



The School Annexe 

Public Health work. Just as it is plainly absurd 
to have several health visitors calling at the same 
house on account of infant welfare, tuberculosis, 
measles, or the following up of defects found in 
children attending the public elementary schools, 
so in the home the nursing of all ailments should 
be performed by one person and not by different 
nurses for different diseases. 

The complete administrative control of the clinic 
must be entirely in the hands of the Medical Officer, 
and he alone should be directly responsible to the 
local authority. Divided responsibility invariably 
leads to overlapping and inefficiency. 



133 



CHAPTER X 
Special Schools 

The systematic medical inspection of school chil- 
dren, as we have seen, has revealed the presence of 
many ailments and defects, some of which prevent 
children from being able to benefit by the instruc- 
tion given in an ordinary public elementary school. 
Fortunately, remedial measures, such as the pro- 
vision of suitable glasses and operations for 
enlarged tonsils, can remove most of these obstacles 
to education ; but there remains a small percentage 
of children, although in the aggregate the number 
may be large, for whom special facilities are re- 
quired, and to meet this need special schools have 
been established. 

Much has been done to provide suitable in- 
struction for children suffering from serious 
degrees of physical and mental defect, yet there are 
still in England and Wales probably not less than 
30,000 for whom no space in a special school is 
available. The wisdom of expending time and 
money in educating children unable to be taught 
in an Ordinary class is now beyond controversy. 

134 



special Schools 

Without assistance, the crippled, dull, or ailing 
child leaves the elementary school at the age of 
14 doubly handicapped by the physical or mental 
weakness, and by the failure to attain a reasonable 
standard of education during school life. He be- 
comes unemployable, a burden on his parents, and 
eventually a charge on the community. On the 
other hand, admission to a special school is likely 
to improve the health of the child, and fit him to 
become a self-supporting unit and, in many in- 
stances, a skilled workman . 

Open-air schools. — Instruction in the open air 
has been practised for many centuries, and to-day 
it may be seen in operation in playground classes, 
nature Study rambles in the country, classes in the 
parks and open spaces; in fact, any teaching in 
the open air and sunlight may be regarded as open- 
air education. The value of this method of training 
is unquestionable; the children improve in health, 
become more alert, and are better able to profit by 
the instruction given. Throughout the country 
there is an urgent call for a great extension of open- 
air teaching. Playground classes and the like can 
easily be arranged at little or no additional cost 
or inconvenience to the working of a school. 
Though, in a few districts, there may be schools so 
deficient in playground and so far removed from 
a park or other space that instruction in the open 
air is impossible, yet it is safe to assert that where 

^35 



The School Child 

a local education authority has the will, suitable 
accommodation can generally be found. 

An open-air school is something more than 
teaching in the open air. The thin, weakly, tired, 
anaemic child, living in an insanitary area, sleeping 
in an overcrowded room, often improperly and in- 
sufficiently fed, needs more than air and sunlight. 
Such a child requires as well food, rest, medical 
attention, and special methods of education, par-i 
ticularly those inculcating personal cleanliness, 
care of the teeth, skin, and hair, physical exercises, 
handicraft classes, and gardening. A close medical 
supervision should be maintained in selecting the 
children to be admitted, the treatment of the ailments 
and defects, and the duration of the child's stay. 

The open-air school should be situated in a 
sunny, sheltered, accessible site, affording ample 
space for physical exercises, play, and gardening. 
An acre to about fifty children is the standard usually 
taken. The buildings may be temporary or per- 
manent. Simplicity in design and economy in con- 
struction are essential. All the rooms should be 
on the ground floor. Each class-room, to accom- 
modate about twenty children, should have a south 
aspect, and may be enclosed on three sides only, 
or the windows can be made to fold back so that 
the front of the room is removed. In order that 
the school may be occupied through the year, 
heating will be necessary. 

136 



Special Schools 

It is generally more economical in the end to 
instal a low-pressure hot-water system. Lavatories, 
shower-baths, cloak-room, closets, a kitchen, 
dining-room, scullery, and medical-treatment room 
must be provided, and a large resting room or shed, 
with a canvas stretcher and rug for each child. A 
head teacher, a trained nurse, five class teachers, 
a cook, and three domestic servants will be required 
for a school of about lOO children. The daily 
routine will vary according to local circumstances. 
Broadly, it may be said that the children should 
attend early and leave late. On reaching the 
school, about 8 o'clock, they should have break- 
fast ; nature study, manual work, and the ordinary 
school subject would occupy the morning; dinner 
would follow^ and then an interval of an hour and 
a half for lying down. In the afternoon a further 
period of class instruction, and then tea. Every 
child should possess a labelled toilet outfit, and 
should daily have a bath. In summer the children 
should leave about 6 or 7 o'clock. 

Local education authorities which have done 
pioneer work in the open-air movement have shown 
conclusively that it is essential to link up in the 
closest manner possible the special school and the 
School Medical Service, so that medical super- 
vision may be complete, from the home to school, 
and the improvement in health gained under the 
regime of the school may be maintained by suitable 

^37 



The School Child 

advice to the parents and by the removal, by 
ordinary Pubhc Health measures, of insanitary 
conditions in the home. 

The ground gained in the day may be lost in 
the night. 

Open-air residential schools. — These schools 
have been established to meet the case of children 
whose home circumstances are so unsatisfactory 
that it is hopeless to attempt to cure until they are 
removed from home so that continuous medical 
and nursing attention may be maintained for a long 
period. 

There are as well children suffering from 
long-standing defects that require many months' 
persistent treatment under open-air conditions — 
quiescent heart disease, anaemia, and intractable 
malnutrition. 

Instances of tuberculosis or other infectious ill- 
ness should not be admitted to the residential 
school. 

The site need not be close to the district from 
which the children come; in fact, it is generally 
better to arrange for the school to be at least five 
or six miles from the homes of the children. In 
area and plan of construction it should not differ 
largely from the open-air day school, except in so 
far as accommodation must be provided for dor- 
mitories, laundry, and staff quarters. An isolation 
ward is advisable, if only for suspected cases of 

138 



special Schools 

disease. The institution should be under the con- 
trol of a medical superintendent, and a matron 
must reside on the premises. The teaching staff 
should be non-resident, and as far as possible or- 
dinary school work should be relaxed in favour of 
handicraft and outdoor manual occupations. Or- 
ganised games, country walks, and nature study 
should be freely undertaken. 

The treatment of defects, such as enlarged ton- 
sils and decayed teeth, should be carried out before 
admission to the school, and it is important that 
careful inquiry and a medical inspection should be 
made on entry to eliminate infectious diseases. 
During residence at the school the children should 
be seen by a dentist at least once a month. 

Medical officers and others who have worked in 
industrial areas and have been brought into contact 
with the homes of the people realise the pressing 
need for the provision of residential schools on 
open-air lines. 

The experience of the War has shown that a 
suitable generous dietary, regular exercise, and 
open-air life can bring about a marvellous change 
in the physique of young adults. Weedy, anaemic, 
narrow-chested lads from workshops and offices, 
after some months of army routine become sturdy, 
self-reliant men, and it is a happy omen that in 
the majority of cases they appreciate the factors 
which have led to the change in health, and have 

139 



The School Child 

the wish to continue the habits involved in a 
hygienic way of life. 

The extent to which various authorities should 
establish residential schools must plainly be 
governed by local conditions, the type of the dis- 
trict, and the amount of insanitation therein. 

A cautious estimate would allow for one school, 
accommodating loo children, for every 20,000 
children attending the public elementary schools. 

A residential school should not be used for the 
reception of incurable ailments; for these, hos- 
pitals and other institutions are available. The 
child most appropriate for admission, bearing in 
mind that the cost of maintenance per bed will 
always be relatively high, is one likely to be com- 
pletely restored to health within a year and un- 
likely to relapse under the conditions of ordinary 
school life. Children who are recovering from 
pneumonia and other illnesses generally respond 
quickly to treatment, and it might be well to look 
upon these residential schools as convalescent 
schools or schools of recovery. 

School camps. — Already in a few areas an 
attempt has been made to follow up advances in 
open-air education by the experiment of school 
camps. 

All the children at a school, together with the 
teachers, spend two or three weeks under canvas 
in a district accessible to the homes. The routine 

140 



special Schools 

teaching of the schools is modified somewhat, and 
two or three meals are served during the day. At 
night the children return to their homes.^- 

It is not surprising to learn that favourable re- 
sults are seen in improved health and general well- 
being. Everyday experience shows that children 
living in urban areas require every year a period 
of change of surroundings. To the average child 
in the public elementary school a summer holiday 
of more than a few days is an impossibility. The 
holiday camp, however, opens the way, and it is 
to be hoped that every urban authority will make 
use of this opportunity of affording every child an 
annual respite from the dirty streets and polluted 
air almost inseparable from industrial towns. 

A camp to accommodate 250 children should 
consist of about seven tents, with a large dining 
tent. A kitchen, store-room, ablution sheds and 
closets must be provided. 

In fact, the camps and hutments which have 
arisen during the War are in many instances 
admirable examples upon which a small school 
camp should be modelled. Probably it is well to 
make the kitchen and other offices permanent struc- 
tures, and to put up the tents as early each year 
as the season permits. 

By arranging a rota over a period of six months, 
a camp for 250 would serve a school population 
of 4,000 to 5,000 children. 

141 



The School Child 

It is unlikely that all the infants' departments 
would be able to attend. 

The success of school camps, measured in terms 
of improved health and the enjoyment obtained by 
the children, irresistibly indicates the need for 
further developments along similar lines. The 
senior departments of a school might live for two 
or three weeks each year in a hutment, within 
moderately easy reach of the homes ; and the camp 
could possess a permanent administrative staff to 
deal with the catering and general management. 
The teaching staff and the children would then 
occupy the camp until succeeded by another school. 

The sanatorium school for pulmonary tuber- 
culosis. — Pulmonary tuberculosis is a compara- 
tively rare disease in children of school age. Never- 
theless, adequate provision should be made to place 
each infected child under conditions best calculated 
to arrest the disease and to prevent transmission 
to healthy children. There are three main lines 
along which the treatment can be carried out. 

First, the child can continue to attend an ordin- 
ary elementary school, and receive free meals, while 
the course of lessons is somewhat lightened. Visits 
to a dispensary at regular intervals will allow for 
medical attention. Secondly, the child may be 
admitted into an open-air day school specially set 
apart for tuberculous children. The construction, 
equipment, and general routine of such a school 

142 



special Schools 

will closely follow that of an open-aif school for 
delicate children, with the addition of more fre- 
quent and more complete medical supervision, the 
systematic taking of temperatures, and some modi- 
fication in physical exercise and games. Thirdly, 
there will remain a number of children for whom 
residential accommodation will be necessary in a 
sanatorium school. This institution, which should 
be sufficiently large to allow of some grading of 
the children for teaching purposes, should not be 
within the grounds of a sanatorium for adults, 
although it may be convenient for administrative 
purposes to have the two buildings under one 
control. A number of small wards, each containing 
six to eight beds, will be required, together with 
one or two single-bedded cubicles for cases of 
serious illness or for isolation purposes. Dining- 
rooms and playrooms must be provided, and the 
usual bath-rooms and closets. Facilities for medi- 
cal and dental examination and treatment will be 
needed. The educational routine will approximate 
to that of an open-air residential school. As many 
of the children will bie able to get up, some simple 
structure will be necessary for the class-rooms, and 
in fine weather the teaching can be given on the 
verandas or in the grounds. A residential medical 
superintendent should be in charge of the institu- 
tion, and must decide which of the children are able 
to attend the classes. One teacher to every twenty 

143 



The School Child 

to twenty-five children will be required, and it is 
important to select one specially trained for the 
wprk. 

As one of the reasons for the establishment of a 
sanatorium school is to ensure that a child unfit 
on account of pulmonary tuberculosis to attend a 
public elementary school shall not lose several 
months or, it may be, years of education, only 
those children should be admitted who are likely 
to be able to lead a fairly active life — that is to say, 
moderately early cases of the disease. Children 
suffering from advanced tuberculosis should be 
treated in a hospital or sanatorium, and not in a 
sanatorium school. 

At the present time a very real need exists for 
the provision of further accommodation for children 
in the early stages of disease, and among the affec- 
tions for which early treatment can be given with 
a reasonable hope of success, tuberculosis of the 
lungs has a foremost place. As there are few areas 
in which there are enough children needing such 
treatment to warrant the building of a large sana- 
torium school, it is advisable for neighbouring 
education authorities to combine in a joint scheme. 

Sanatorium school for surgical tuber- 
culosis. — Tuberculosis of bones and joints is re- 
sponsible for the greater part of the deformities of 
children, including the hunch back, and one form 
of hip-disease. 

144 



special Schools 

It is unfortunately true that in scarcely one 
school area is there adequate provision for dealing 
with the ravages of this crippling infection. Under 
modern methods of open-air treatment, with com- 
plete immobility of the affected part for several 
months, and in some instances for more than a year, 
recovery is likely to be complete. 

In many cases hardly a trace of deformity is 
left. With a few exceptions, the alternatives for a 
child suffering from surgical tuberculosis now lie 
between treatment at home and admission into a 
general hospital. The former is hopeless, the latter 
as a rule unsatisfactory. 

In the average home it is impossible, even with 
the daily visits of a nurse, to secure the continuous 
attention, absolute rigidity, fresh air, sunlight, and 
suitable food that are essential for success. 

Comparatively few general hospitals possess a 
fully-equipped orthopaedic department under the 
direction of a surgeon who is a specialist in the 
work. None has sufficient accommodation to cope 
with all the requests for admission. The ever- 
urgent call of new patients irresistibly leads to the 
too-early discharge of those under treatment. 

As soon as tuberculosis of bone or joint is dis- 
covered, the child should be taken into a sanatorium 
school. In site and surroundings this institution 
is an open-air residential school. In construction, 
some modifications must be made to fit the building 



The School Child 

for the special treatment to be carried out. Wards 
containing about ten beds each, the south side 
opening on to a veranda, should be provided, and 
an operating theatre, plaster room, and X-ray room 
will be necessary, with dining-rooms, day-rooms, 
and one or two class-rooms or workshops for the 
children who are able to move about. The staff 
quarters and administrative offices should be in 
a separate building. 

As many of the patients remain in bed for long 
periods, the arrangements for teaching must be 
somewhat elastic, and allow for instruction being 
given in the wards to children recumbent in bed. 

The sanatorium school should be under the 
charge of a resident medical officer, and should 
provide accommodation for not less than 150 to 200 
children. The larger the institution, the more effi- 
cient are the facilities for treatment and teaching 
likely to be. 

An orthopaedic surgeon and a dentist should 
visit the school at regular intervals. 

When the child leaves the sanatorium school, 
constant watch must be kept over its home sur- 
roundings and state of health. 

If possible, attendance at an open-air school 
should be permitted for a year or two. 

A cripple -school may be regarded as an 
open-air day-school, mainly admitting quiescent 
cases of deformity — ill-nourished, anaemic, breath- 

146 



special Schools 

less children who are crippled dj disease no longer 
active. Unless the site is readily accessible, steps 
must be taken to convey to and from the school the 
children who find a difficulty in walking. The 
furniture provided must be suitable for the needs 
of each scholar. Adjustable tables, wicker chairs, 
cushions, back-rests, supports of various kinds, 
and wheel chairs will be required. Remedial 
physical exercises should be given under medical 
supervision, and in view of the permanent nature 
of many of the deformities, manual work and the 
teaching of a trade are essential to equip the 
children for the struggle before them on leaving 
school. The staff should include a head teacher, 
class teachers, and domestic servants. A nurse 
should be present during the whole of the day, and 
a medical officer should, at frequent intervals, 
systematically examine each child. 

Special schools for the blind and deaf. — 
Education authorities, particularly those dealing 
with large numbers of children, should seriously 
consider the erection of day-schools and residen- 
tial schools for the blind and deaf. The need for 
such accommodation is pressing, and it is surely 
time to shed the prevailing impression that a blind 
person does not require or appreciate cheerful 
surroundings, sunlight, and fresh air. 

Bright, airy class-rooms, workshops, dormi- 
tories, and dining-rooms should be part of a 

147 



The School Child 

residential school for the blind and deaf. Domestic 
work, gardening" and farm work, and poultry- 
keeping should be taught. Careful instruction in 
Braille is necessary in the case of the blind, and, 
for the deaf, lip reading and voice production. The 
teachers themselves should have had an efficient 
training. The main objects to be achieved in at- 
tempting to educate the children are firstly to 
build up a sense of security and self-reliance, and 
secondly to evolve craftsmen skilled in remunera- 
tive branches of work. 



148 



INDEX 



Accommodation, minimum, of 
healthy home, 30 

Adenoids, 2 ; and malnutrition, 
25 ; and deafness, 48 

After-care of mentally abnormal 
children, necessity for, 102 ; 
organisation of, 103 

Air, lack of, as cause of mal- 
nutrition, 19 

Anaemia, and oral sepsis, 27; 
open-air schools for, 

138 

pernicious, pyorrhoea and, 

35 , ^ 
Annexe, school, 118 
Ante-natal conditions, bad, effect 

of, on children, 5 
Artificial feeding, and health of 

children, 10, 13 
Ashpits, and health of children, 

12, 22 
Astigmatism, 43 
Attendance, school, as affected 

by illness, 74 



Backward children, education 
of, 92 

Baths, school, 126, 127 

Blackboards, 115 

Blind and deaf, special schools 
for, 46, 147 

Bronchitis, as cause of malnutri- 
tion, 27 ; prevalence of, among 
school children, 60 ; prevention 



of, 64; treatment of, 64; as 
cause of backwardness, 93 
Broncho-pneumonia, 33, 62 



Camps, school, 140 

Canteens, school, 19, 33, 118; 

organisation of, 120 
Caries, dental, 26, 37 
Centres, play, 128 
treatment, 128 ; staffing of, 

131 

Chilblains, 66 

Child labour, ill effects of, 28 

Chorea, and rheumatism, 26; 
and heart disease, 57, 58 

Classes, special, for defective 
sight, 45 ; for deafness, 51 ; 
for stammering, 54, 55; for 
backward children, 93 ; for the 
dull, 95 ; for the feeble-minded, 

Class-rooms, construction ot, 
108 ; ventilation of, 108 ; heat- 
ing of, 109 J seating accommo- 
dation in, 113; appliances of, 

113 

Clinics, school, 40, 128 ; medical 

staff of, 131 ; nursing staff of, 

132 
Cloak-rooms, school, 59, in 
Cold in the head, prevention or 

checking of, 49 
Colonies, for mentally abnormal 

children, 99 



149 



Index 



" Contacts," exclusion of, from 
school, 75 ; an alternative to, 

77 
Cornea, ulcers of, 42, 43, 44 
Cripple-children, 79 ; unsuita- 
bility of ordinary schools for, 
80 ; approximate number of, 
81 ; schools for, 144, 146 
Cuts and sores, 66 



Dancing, teaching of, in schools, 
123 

Deaf children, education of, 51 

Deafness, causes of, 47 ; preven- 
tion of, 48 

Deformities, 79 ; treatment of, 
81 ; utilisatioo of war institu- 
tions for treatment of, 81 ; pre- 
vention of, 82 

Dental caries, 26, 35 ; causes of, 
37 ; treatment of, 39 

clinics, 40, 131, 132 

diseases, 35 ; prevention of, 

39 

inspection in schools, 39 

■ treatment in schools, 2, 39, 

102, 132 
Desks, school, 88, 113 
Development, defects of, 82 ; 

treatment of, 89 
Diarrhoea, summer, and malnu- 
trition, 25 
Diphtheria, and malnutrition, 
25 ; and middle-ear 
disease, 48 
Diseases, infectious, 23 ; imporit- 
ance of nursing in, 49; 
measures to prevent 
spread of, in schools, 75 
Disinfection, as a preventive of 

scabies, 69 
Dull children, 94 ; training of, 
95 



Ear, discharging, 25, 47 

mechanism of, 46 ; diseases 

of, 47 
Employment of school children, 

undesirability of, 28 
Endocarditis, 56, 57 ; prevention 

of, 58 ; treatment of, 60 
Enteritis, 25 
Environment during babyhood, 

effect of, on health of school 

child, 14 
Epileptic children, 100 ; training 

of, lOI 
Eye, diseases of, 42 ; treatment 

of, 44 
Eyelids, sore, and malnutrition, 

25 ; and insanitary homes, 42 ; 

as cause of backwardness, 93 
Eyestrain, 41, 44 



Faulty posture, as cause of 
deformity, 88 

Feeble-minded children, 95 ; day- 
school accommodation for, 97 ; 
residential schools for, 99 ; 
permanent homes for, 99 

Food, insufficient and unsuit- 
able, 18 ; contaminated, 22 

Free meals, 33, 120 



Games, organisation of, 123, 
125 ; for feeble-minded chil- 
dren, 98 

Glands, enlarged, as cause of 
ibackwaxdness, 93 

" Growing pains," significance 
of, 26, 57; treatment of, 59 

Gymnasium, school, 122 



Hall, school, 107 
Headache, 27 
Health visitors, 15 



150 



Index 



Healthy childhood, national im- 
portance of, 3 

Hearing, defects of, 46 

Heart, organic disease of, 56 ; 
functional disorders of, 57 

Heating of schools, 109 

Home, healthy, minimum re- 
quirements of, 30 

nursing service, 14; scope 

fox, 28, 33 

visiting, 28, 78 

Hospital accommodation for 
diseases of children, need for 
further, 32 

Hygiene, oral, 39, 49 ; nasal, 
49 ; in heart disease, 59 ; 
teaching of, 73 ; in feeble- 
mindedness, 98 

Impetigo, 24, 66 

Indigestion, oral sepsis and, 27 

Infant mortality, ante-natal in- 
fluences and, 6 ; rate of, as 
affected by size of family, 11 

Infantile paralysis, as cause of 
crippling, 14, 82, 85 ; treatment 
of, 86, 89 ; prevention of, 86 ; 
as cause of feeble-mindedness, 
.96 

Infectious diseases {see Diseases, 
infectious) 

Influenza, epidemic of, 1 

Injuries, treatment of, in school 
clinics, 73 

Insanitary homes, a factor in 
malnutrition, 19 

Iritis, 42 

Itch (see Soabies) 

Jaw, deformity of, 53 
Joints, pains in, oral sepsis and, 
26, 27 

Lavatoeies, school, no 



Lighting of schools, 106, 107, 

108; artificial, 115 
Long sight, 43, 44 
Lung diseases, 60; prevention 

of, 63 ; treatment of, 64 

Malnutrition, 2, 8, 16 ; in- 
sufficient and unsuitable food 
and, 18; insanitary homes 
and, 19 ; insanitary yards and 
streets and, 22 ; lack of sleep 
and, 24 ; disease and, 24 ; un- 
suitable employment and, 27 j 
mateinal education and, 28 ; 
prevention of, 28; institu- 
tional treatment of, 31 ; home 
nursing service and, 32 ; free 
meals and, 33; open-air resi- 
dential schools and, 138 

Maternal ignorance, effects of, 

19 

sickness, effects of, 8 

Maternity centres, 14, 28, 38, 85 

Meals, free, 33, 120 

Measles, and malnutrition, 24, 
25, 32, 33 ; and diseases of the 
eye, 42 ; and diseases of the 
ear, 48, 49 

Medical inspection, school, 17, 
36 (see also Clinics) 

treatment, school, 102 (see 

also Clinics) 

Mentally abnormal children, gi ; 
classification of, 92 ; training 
of, 93 ; after-care of, 102 

Middens, privy, and health of 
children, 12, 21 

Middle-ear disease, 48; treat' 
ment of, 50 

Milk, tuberculous, 83 

Ministry of Health, and re- 
organisation of health admin- 
istration, 15 

Minor ailments, 2, 66; treat- 
ment of, at school, izg 



151 



Index 



Mothercraft, teadhing of, to 
mothers, 28 ; to elder girls, 29 

Motherhood, early, and infant 
mortality, 9 

Mouth-breathing and deafness, 
48 

Nursery schools, and detection 

of disease, 85 
Nurses, school, and prevention 

of infectious disease, 77 
Nursing, importance of, in in- 
fectious disease, 49 
service, home, need for ex- 
tension of, 14; scope for, 
28, 33 

staff of school clinics, 132 

Nutrition, 16 



Pediculosis, 66 

Play centres, 128 

Playgrounds, school, 106, 134 

Playing-fields, school, 125 

Pneumonia, 33, 57, 132 

Pocket-handkerchief drill, 50, 
123 

Poliomyelitis {see Infantile 
paralysis) 

Posture, faulty, as cause of 
deformity, 88 

Pre-tubercular state, 24 

Privy middens, and malnutri- 
tion, 12, 21 

Pulmonary tuberculosis (see 
Tuberculosis, pulmonary) 

Purulent ophthalmia, 43 

Pyorrihoea, 35 



Occupation, parental, effects of, 

on health of children, 9 
Open-air classes, 75 ; in treat- 
ment of bronchitis, 64 
— — residential schools, 138 

schools, 135 

Ophthalmia, 33, 132 
neonatorum, 43 

Oral sepsis, and malnutrition, 26 

Overcrowding, domestic, as 

cause of malnutrition, 20 

of teeCh, 36 

Overwork, and malnutrition, 27 

Pail closets, and health of chil- 
dren, 12; in schools, 113 
Pains, joint, 26, 27 
Parental inexperience, effects of, 
on health of children, 9, 
12 

sickness, effects of, on 

health of children, 8 
Passages, insanitary, and health 
of children, 23 



Rashes, transient, and rheu- 
matism, 26 

Refraction, errors of, 42 ; cor- 
rection of, 44 

Refuse accommodation, insani- 
tary, 21, 22 

Residential schools {see Schools, 
tesidential) 

Rheumatism, acute, and malnu- 
trition, 26; and diseases 
of the eye, 42 ; and heart 
disease, 57 

subacute, and heart dis- 
ease, 57, 58 

Rickets, as cause of crippling, 
87 ; prevention of, 87 ; treat- 
ment of, 89 

Ringworm, 66 ; prevention of, 
67 ; treatment of, 68 ; as a 
cause of backwardness, 93 



St. Virus's dance, and rheu- 
matism, 26, 57, 58, 59 



152 



Index 



Sanatorium schools, for pulmon- 
ary tuberculosis, 142 ; for 
surgical tuberculosis, 144 

treatment of lung diseases, 

64 
Sanitary conveniences in 

schools, 112 
Sanitation, defective, and health 

of children, 12 
Scabies, 69 ; prevention of, 69 ; 

treatment of, 70 
Scarlet fever, 48, 49, 57 ; spread 

of, 76 
School annexe, 118 

attendance, as afifected by 

Illness, 74 
baths, 126, 127 

buildings, influence of, 

on children, 104 ; defec- 
tive, 105 ; situation and 
site of, 105 ; aspect of, 
106 ; minimum area of, 
106 ; division of, into de- 
partments, 106 ; construc- 
tion of, 107 ; hall of, 107 ; 
floor space of, 107 ; class- 
rooms of, 108 ; heating 
of, 109 ; water supply of, 
1 10 ; washing facilities 
of, 110; cloak-rooms of, 
HI ; sanitary accommo- 
dation of, H2; seating 
accommodation of, 113; 
artificial lighting of, 115; 
accommodation in, for 
teachers, 116 

camps, 140 

clinics (see Clinics, school) 

dental service, 132 

medical officers, and esti- 
mation of nutrition, 
17 ; and employment of 
children, 28 ; and exam- 
ination of stammerers, 
S3» 55 ; 3,nd infestation 



with vermin, 72 ; and 
surgical tuberculosis, 
85 ; and mentally abnor- 
mal children, 91, 96; 
and work of school can- 
teen, 121 ; staff of, 129, 
131 ; and direct respon- 
sibility for school clinic. 

School nurses, work of, 77 

Schools, residential, for heart 
disease, 60; for mentally 
abnormal children, 99 ; 
open-air, 138; for pul- 
monary tuberculosis, 143 ; 
for surgical tuberculosis, 
145 ; for blind and deaf, 
46, 147 

special, for mentally ab- 
normal children, 97 ; 
open-air, 135 ; open-air 
residential, 138; for pul- 
monary tuberculosis, 142 ; 
for cripples, 146 ; for 
blind and deaf, 147 (See 
also Schools, residential) 

Seating accommodation in class- 
rooms, 113 

Short sight, 43, 44 

Sight, defects of, 41 ; treatment 
of, 44 ; and stammering, 53 

Slates and sponges, unsuitability 
of, in schools, 114 

Sleep, lack of, as cause of mal- 
nutrition, 24 

Sore throat, 26 ; as cause of 
backwardness, 93 

Sores and cuts, 66 

Special schools {see Schools, 
special) 

Spectacles, 44 

Speech, defects of, 52 

Sponges and slates, unsuitability 
of, in schools, 114 

Squint, 43 



153 



Index 



Staff, teaching, accommodation 
for, ii6 

Stammering, causes of, 52 ; pre- 
vention of, 53 

Streets, insanitary, 22, 30 

Summer diarrhoea, and malnu- 
trition j 25 

Sunlight, lack of, as cause of 
malnutrition, 19 

Surgical tuberculosis {see Tuber- 
culosis, surgical) 

Swedish exercises, 122 

Swimming, teaching of, 126 



Teachers, accommodation for, 
116 

Teeth {see Dental) 

Tonsils, enlarged, 2 ; and mal- 
nutrition, 25 ; and deafness, 
48 ; and stammering, 53 ; and 
rheumatism, 57, 59 

Toothbrush drill, 39 

Towels, common, undesirability 

of. 73 

Treatment centres, 128 

Tuberculosis, as factor in mal- 
nutrition, 24 

pulmonary, 61 ; prevention 

of, 63; treatment of, 



64 ; special schools for, 
142 

Tuberculosis, surgical, as cause 
of crippling, 82, 83 ; pre- 
vention of, 83 ; treatment 
of, 84, 88; sanatorium 
schools for, 144 

Twitchings of face and limbs, 58 



Valvular disease, 57 

Venereal disease, and infant 

mortality, 8 
Ventilation of schools, 107 
Verminous children, treatment 

of, 71 
Vision {see Sight) 



Washing accommodation in 

schools, no 
Water supply for schools, no 
Whooping-cough, 10, 14 ; and 

malnutrition, 24, 33 



X-rav treatment of ringworm, 
68 

Yards, insanitary, 22 



Printed sy Cassell & Company, Limited, La Belle Sauvage, London, E.C.4 

p 20.919 



